Written by Shannon Markus
Spoon Feed
In adult stroke patients eligible for both mechanical thrombectomy and IV thrombolytics (IVT), IVT should be offered and may be administered before thrombectomy.
Bridging the gap in stroke care
Approximately 30% of acute ischemic strokes involve large vessel occlusion (LVO), contributing significantly to stroke-related disability and mortality. The American College of Emergency Physicians (ACEP) has updated its 2015 clinical policy on thrombolytic use in acute stroke, now considering LVO patients who are eligible for both IV thrombolysis (IVT) and endovascular therapy (EVT), such as mechanical thrombectomy. There is debate regarding the use of IVT before EVT as EVT availability increases. IVT may aid early reperfusion and dissolve residual thrombi after EVT, but could also cause emboli fragmentation and distal embolization.
This systematic review assessed outcomes in non-pregnant adults with LVO stroke receiving EVT with or without IVT. Of 557 articles identified, 18 met methodological standards for inclusion. The review addressed whether IVT before EVT (bridge therapy) is beneficial and safe compared to EVT alone.
– Level B recommendation: IVT should be offered and may be given before mechanical thrombectomy in eligible stroke patients.
– Level C recommendation: When feasible, shared decision-making should involve discussing IVT’s potential benefits and risks with the patient or surrogate prior to the decision whether to administer intravenous thrombolytics (Consensus recommendation).
Potential benefits include improved functional outcomes and reduced mortality. Risks include EVT delays and higher treatment costs. Most studies showed no increased mortality or incidence of ICH with IVT + EVT. Further research is recommended on alternate thrombolytics (e.g., tenecteplase), IVT timing, and effects on posterior strokes.
How will this change my practice?
Like many others, I practice at a handful of hospitals, some with EVT capabilities and some without. This clinical policy is tremendously helpful to me, as it supports the initiation of IVT for LVO stroke patients at one of my smaller hospitals, potentially improving chances of a favorable neurological outcome.
Source
Use of Thrombolytics for the Management of Acute Ischemic Stroke in the Emergency Department. Ann Emerg Med. 2024 Dec;84(6):e57-e86. doi: 10.1016/j.annemergmed.2024.07.023. PMID: 39578010
