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In patients with large vessel occlusions(LVO) presenting 4.5-24 hours after onset, without access to endovascular thrombectomy (ET), tenecteplase(TNK) administration bested standard medical treatment(SMT) in 90-day disability-free recovery.

Source
Tenecteplase for Ischemic Stroke at 4.5 to 24 Hours without Thrombectomy. N Engl J Med. 2024 Jun 14. doi: 10.1056/NEJMoa2402980. Epub ahead of print. PMID: 38884324.

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For acute ischemic stroke patients with recent DOAC ingestion who (1) had their DOAC level measured, (2) had DOAC reversal with idarucizumab, or (3) inadvertently received thrombolytics with DOAC subsequently discovered, there was not evidence of increased significant intracranial hemorrhage associated with off-label thrombolytic therapy.

Source
Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. JAMA Neurol. 2023 Mar 1;80(3):233-243. doi: 10.1001/jamaneurol.2022.4782. Erratum in: JAMA Neurol. 2023 Apr 1;80(4):422. doi: 10.1001/jamaneurol.2022.5395. PMID: 36807495; PMCID: PMC9857462.

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This was an exploratory analysis of the recently published SELECT2 trial, which randomized 352 adults with acute ischemic stroke due to carotid or M1 MCA occlusion to endovascular thrombectomy (EVT) or medical management. The current analysis showed that EVT was superior in functional outcomes across a variety of ischemic severities and penumbra profiles on imaging.

Source
Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles. JAMA. 2024;331(9):750-763. 

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In patients with anterior circulation large-vessel occlusion (LVO) stroke presenting to thrombectomy capable stroke centers, the benefit of intravascular thrombolysis in the setting of endovascular thrombectomy appears to be time-dependent.

Source
Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis. JAMA. 2024 Mar 5;331(9):764-777. doi: 10.1001/jama.2024.0589. PMID: 38324409; PMCID: PMC10851137.

Exciting news! JournalFeed and Dr. Amal Mattu's Top Picks Video Series is set to GO LIVE this week! It's free for Gold Spoon members or you can just get the video series. Watch this trailer and get excited!

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In this retrospective cohort study, there was no increased risk of intracranial hemorrhage, major bleeding, or in-hospital mortality in patients taking non-vitamin K antagonist oral anticoagulants compared to those not taking anticoagulants, but read the fine print.

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Endovascular thrombectomy plus medical care is better than medical care for patients with large vessel occlusion (LVO), even with established large infarcts.

Source
Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet. 2023 Nov 11;402(10414):1753-1763. doi: 10.1016/S0140-6736(23)02032-9. Epub 2023 Oct 11. PMID: 37837989.

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More aggressive systolic blood pressure (SBP) goals, beyond keeping it <180 mmHg, probably don’t make much of a difference in outcomes for patients who have undergone endovascular therapy for ischemic stroke.

Source
Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial. JAMA. 2023 Sep 5;330(9):821-831. doi: 10.1001/jama.2023.14330.

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This ACEP Clinical Policy examined four specific clinical questions related to ED management of acute ischemic stroke, which are summarized below.

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In minor acute ischemic stroke (AIS) patients presenting within 4.5 hours of onset, dual antiplatelet therapy (DAPT) is non-inferior to intravenous alteplase for excellent neurologic outcome at 90 days.

Source
Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial. JAMA. 2023 Jun 27;329(24):2135-2144. doi: 10.1001/jama.2023.7827.

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Tenecteplase was non-inferior to alteplase in patients with acute ischemic stroke who were eligible for intravenous thrombolytic therapy but ineligible or refused endovascular thrombectomy.

Source
Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial. Lancet. 2023 Feb 8;S0140-6736(22)02600-9. doi: 10.1016/S0140-6736(22)02600-9. Online ahead of print.