Author: Li Ruijie
From: "Literature Study of Neurology and Critical Care Medicine"
Treatment within 4.5 hours after onset
Intravenous thrombolysis using alteplase in patients with acute ischemic stroke lasting 4.5 hours Does treatment have better functional outcomes than no intravenous thrombolysis?
Recommendation: For patients with acute ischemic stroke with a duration of 4.5 hours, we recommend intravenous thrombolysis with alteplase. Quality of evidence for : high, strength of recommendation: strong.
Treated between 4.5-9 hours after known onset (without using advanced imaging)
In patients with acute ischemic stroke selected between 4.5-9 hours (known time of onset) with plain CT, altepro Does enzymatic intravenous thrombolysis have a better functional outcome than no intravenous thrombolysis?
Recommendation: We do not recommend intravenous thrombolysis for patients with acute ischemic stroke lasting 4.5-9 hours (known time of onset) without other brain imaging examinations other than plain CT scan. Quality of evidence for : moderate, strength of recommendation: strong.
Treated between 4.5-9 hours after known onset (using advanced imaging)
Treated between 4.5-9 hours in duration (known time of onset) with CT or MRI core/perfusion mismatch Ischemic stroke In patients, does intravenous thrombolysis with alteplase lead to better functional outcomes than without intravenous thrombolysis?
Recommendation: For patients with ischemic stroke of duration 4.5-9 hours (known time of onset) and CT or MRI core/perfusion mismatch*, and who are not candidates for or not planned for mechanical thrombectomy, we recommend A Teplase was used for intravenous thrombolysis. Quality of evidence for : low, strength of recommendation: strong.
* In the individual participant data meta-analysis conducted by Campbell et al., using automated processing software to assess core/perfusion mismatch, was defined as follows:
-core infarction** volume 70ml
-and severe hypoperfusion volume/core infarction ** Volume 1.2
- and mismatched volume 10ml
-rCBF30% (CT perfusion) or ADC620mm2/s (diffusion MRI)
-Tmax6s (CT or MRI perfusion)
for patients without CT or MRI core infarction/perfusion mismatch, See the expert consensus statement below.
Expert Consensus Statement
In patients with ischemic stroke of duration 4.5-9 hours (known onset) and CT or MRI core/perfusion matching, all 9 panel members opposed the use of alteplase for IVT.
Expert Consensus Statement
For patients with 4.5-9 hour ischemic stroke (known time of onset) who present directly to a thrombectomy center and have a CT or MRI core/perfusion mismatch and are eligible for mechanical thrombectomy, mechanical thrombectomy There is no consensus on whether intravenous thrombolysis should be performed before treatment.
For patients presenting to a non-thrombectomy center with ischemic stroke duration 4.5-9 hours (known time of onset) and CT or MRI core/perfusion mismatch who are eligible for mechanical thrombectomy, 9 panelists Six recommended intravenous thrombolysis before mechanical thrombectomy.
Stroke after awakening/stroke of unknown onset
Stroke after awakening Stroke /stroke of unknown onset, in patients with acute ischemic stroke of unknown onset, whether intravenous thrombolysis with alteplase has better outcomes than no intravenous thrombolysis Functional results?
Recommendation: For patients with acute ischemic stroke after awakening, whose last normal visit time was more than 4.5 hours earlier, MRI DWI FLAIR mismatch, and patients who have no indication or plan for mechanical thrombectomy, we recommend Intravenous thrombolysis with alteplase. Quality of evidence for : high, strength of recommendation: strong.
We recommend the use of alteplase in patients with acute ischemic stroke upon awakening who develop a CT or MRI core/perfusion mismatch within 9 hours of awakening* and who are not candidates for or not planned for mechanical thrombectomy. Intravenous thrombolytic therapy. Quality of evidence for : moderate, strength of recommendation: strong.In a meta-analysis of individual participant data conducted by
EOS, using automated processing software to assess core/perfusion mismatch, was defined as follows:
-core infarction** volume 70ml
-and severe hypoperfusion volume/core infarction** volume 1.2
-and Mismatch volume 10ml
-rCBF30% (CT perfusion) or ADC620mm2/s (diffusion MRI)
-Tmax6s (CT or MRI perfusion)
Expert consensus statement
Patients with acute ischemic stroke who wake up directly go to the thrombectomy center, and These patients were eligible for IVT and mechanical thrombectomy, and 6 of 9 panel members recommended IVT before MT.
For patients with acute ischemic stroke who went directly to a non-thrombectomy center after awakening and were eligible for IVT and mechanical thrombectomy, 7 out of 9 panel members recommended IVT before MT.
tenecteplase
Does tenecteplase IVT lead to better functional outcomes than alteplase IVT in patients with acute ischemic stroke of duration 4.5 hours?
Recommendation: For patients with acute ischemic stroke whose disease duration is 4.5 hours and who are not suitable for mechanical thrombectomy, we recommend the use of intravenous thrombolysis with alteplase instead of tenecteplase. See the next paragraph for patients eligible for mechanical thrombectomy. Quality of evidence for : low, strength of recommendation: weak.
Is IVT with tenecteplase better than alteplase in patients with acute ischemic stroke of 4.5 hours duration and large vessel occlusion who are candidates for mechanical thrombectomy and who should consider intravenous thrombolysis before thrombectomy? Does IVT lead to better functional outcomes?
Recommendation: For patients with acute ischemic stroke lasting 4.5 hours and large vessel occlusion, who are suitable for mechanical thrombectomy, and intravenous thrombolysis should be considered before thrombectomy, we believe that using tenecteplase 0.25 mg/kg is better than Alteplase 0.9mg/kg intravenous thrombolysis. Quality of evidence for : low, strength of recommendation: weak.
dose
Does intravenous thrombolysis with low-dose alteplase result in non-inferiority (rather than worse) compared with standard-dose alteplase in patients with acute ischemic stroke of duration 4.5 hours? Functional results?
Recommendation: For patients with acute ischemic stroke whose duration is <4.5>: high, strength of recommendation: strong.
Adjuvant therapy (ie, antithrombotic agents, ultrasound)
In patients with acute ischemic stroke of duration 4.5h, does the use of antithrombotic drugs in addition to IVT result in better functional outcomes than IVT alone?
Recommendation: For patients with acute ischemic stroke lasting <4.5>: low, strength of recommendation: strong.
Does ultrasound-enhanced IVT lead to better functional outcomes than IVT alone in patients with acute ischemic stroke of 4.5 hours duration?
Recommendation: For patients with acute ischemic stroke lasting <4.5>: low, strength of recommendation: strong.
Advanced age, morbidity, frailty, or previous disability
In patients over 80 years old with acute ischemic stroke of 4.5 hours duration, does IVT with alteplase result in better functional outcomes than no IVT?
Recommendation: For patients over 80 years old with acute ischemic stroke of 4.5 hours duration, we recommend intravenous thrombolysis with alteplase. Quality of evidence for : high, strength of recommendation: strong.
Expert Consensus Statement
9 panelists agreed that age alone should not be a limiting factor for IVT, even in other settings covered by these guidelines (e.g., wake-up stroke; ischemic stroke of duration 4.5–9 hours (known time of onset), CT or MRI core/perfusion mismatch; minor stroke with disabling symptoms).
In patients with acute ischemic stroke of 4.5 hours duration, who are multimorbid, frail, or previously disabled, does intravenous thrombolysis with alteplase have better functional outcomes than those without intravenous thrombolysis?
Recommendation: We recommend intravenous thrombolysis with alteplase for acute ischemic stroke lasting 4.5 hours and in patients with multiple morbidities, frailty, or prestroke disability. Quality of evidence for : very low, strength of recommendation: weak.
Minor stroke and stroke with rapid improvement in neurologic signs
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute minor disabling ischemic stroke of duration 4.5 hours?
Recommendation: For patients with acute mild disabling ischemic stroke lasting 4.5 hours, we recommend intravenous thrombolysis with alteplase. Quality of evidence for : moderate, strength of recommendation: strong.
Does IVT with alteplase result in better functional outcomes than no IVT in patients with acute mild non-disabling ischemic stroke of 4.5 hours duration?
Recommendation: We do not recommend intravenous thrombolysis for patients with acute mild non-disabling ischemic stroke lasting 4.5 hours. For patients with minor stroke and large vessel occlusion, see the following section. Quality of evidence for : moderate, strength of recommendation: weak.
In patients with acute mild non-disabling ischemic stroke of 4.5 hours duration and proven large vessel occlusion, does IVT with alteplase lead to better functional outcomes than no IVT?
Recommendation: There is insufficient evidence to make an evidence-based recommendation in patients with acute mild non-disabling ischemic stroke lasting 4.5 hours and confirmed large vessel occlusion. See the expert consensus statement below. Quality of evidence for : very low, Strength of recommendation: -.
Expert consensus statement
For patients with acute mild non-disabling ischemic stroke of 4.5 hours duration and large vessel occlusion, 6 of the 8 panel members recommended intravenous thrombolysis with alteplase. One panel member (WW) did not vote or comment on this chapter because he is involved in the data monitoring committee for a trial related to this topic (TEMPO-2).
In patients with acute ischemic stroke lasting 4.5 hours and with rapid improvement in neurologic signs, does IVT with alteplase lead to better functional outcomes than no IVT?
Recommendation: There is insufficient evidence to make a recommendation in patients with acute ischemic stroke lasting 4.5 hours and with rapid improvement in neurologic signs but still disability. See the expert consensus statement below. Quality of evidence for : very low, Strength of recommendation: -.
Expert Consensus Statement
For patients with acute ischemic stroke lasting 4.5 hours, whose neurological signs rapidly improve but remain disabled, 8 of the 9 panel members recommended intravenous thrombolysis with alteplase. The panel agreed that treatment decisions should be based on the clinical status at presentation and that waiting for symptoms to resolve is unreasonable.
Severe Stroke
In patients with severe acute ischemic stroke of duration 4.5 hours, does IVT with alteplase lead to better functional outcomes than no IVT?
Recommendation: For patients with clinically severe acute ischemic stroke lasting 4.5 hours, we recommend intravenous thrombolysis with alteplase. Quality of evidence for : moderate, strength of recommendation: strong.
In patients with acute ischemic stroke of 4.5 hours duration and severe stroke (defined by the extent of early ischemic changes on CT), we recommend that intravenous thrombolysis with alteplase be considered in selected cases (see Expert consensus statement below). Evidence Strength: Very Low, Recommendation Strength: Weak.
Expert Consensus Statement
Hypertension and Hyperglycemia levels
Is IVT with alteplase better than without IVT in patients with acute ischemic stroke of duration 4.5 hours and with persistently elevated blood pressure greater than 185/110mmHg even after antihypertensive therapy? IVT leads to better functional outcomes?
Recommendation: For patients with acute ischemic stroke lasting 4.5 hours, if systolic blood pressure continues to rise by 185 mmHg or diastolic blood pressure by 10 mmHg even after antihypertensive treatment, we do not recommend intravenous thrombolytic treatment. Quality of evidence for : very low, strength of recommendation: strong.
In patients with acute ischemic stroke of 4.5 hours duration, with blood pressure rising above 185/110mmHg and subsequently falling below 185/110mmHg, does IVT with alteplase result in better functional outcomes than no IVT?
Recommendation: We recommend intravenous thrombolysis with alteplase for patients with acute ischemic stroke lasting 4.5 hours and with systolic blood pressure of 185 mmHg or diastolic blood pressure of 110 mmHg (subsequently reduced to 185 and 110 mmHg). Quality of evidence for : low, strength of recommendation: strong.
Is intravenous alteplase associated with better functional outcomes than no intravenous thrombolysis in patients with acute ischemic stroke lasting 4.5 hours and known prestroke hypertension?
Recommendation: For sustained For patients with acute ischemic stroke within 4.5 hours and known prestroke hypertension, we recommend intravenous thrombolysis with alteplase. Quality of evidence for : moderate, strength of recommendation: strong.
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke of 4.5 hours duration and blood glucose levels above 22.2 mmol/L (400 mg/dL)?
Recommendation: We recommend intravenous thrombolysis with alteplase for patients with acute ischemic stroke that lasts 4.5 hours and whose blood glucose level is higher than 22.2mmol/L (400mg/dL). Quality of evidence for : very low, Strength of recommendation: weak.
Intravenous thrombolysis should not interfere with insulin therapy in patients with acute ischemic stroke and hyperglycemia.
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke of 4.5 hours duration and known diabetes ?
Recommendation: For patients with acute ischemic stroke lasting 4.5 hours and known diabetes, we recommend intravenous thrombolysis with alteplase. Quality of evidence for : moderate, strength of recommendation: strong.
Use of antithrombotic drugs before stroke
Whether IVT with alteplase results in better function compared with no IVT in patients with acute ischemic stroke antiplatelet drugs and duration 4.5 hours result?
Recommendation: We recommend intravenous thrombolysis with alteplase in patients with acute ischemic stroke lasting 4.5 hours and who were taking single or dual antiplatelet drugs before the stroke. Quality of evidence for : low, strength of recommendation: strong.
In patients with acute ischemic stroke taking a vitamin K antagonist for a duration of 4.5 hours, does IVT with alteplase lead to better functional outcomes compared with no IVT?
Recommendation: For patients with acute ischemic stroke lasting 4.5 hours, taking a vitamin K antagonist and INR <1.7,>: low, strength of recommendation: strong.
We do not recommend intravenous thrombolytic therapy in patients with acute ischemic stroke of 4.5 hours duration, taking vitamin K antagonists, and INR1.7. Quality of evidence for : very low, strength of recommendation: strong.
We do not recommend intravenous thrombolysis in patients with acute ischemic stroke lasting 4.5 hours, taking vitamin K antagonists, and with unknown coagulation test results. Quality of evidence for : very low, strength of recommendation: strong.
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke who are on NOACs for a duration of 4.5 hours?
Recommendation: For patients with acute ischemic stroke of duration 4.5 hours, use of NOACs in the last 48 hours before stroke and for whom no specific coagulation test is available (i.e. calibrated anti-Xa activity of factor Xa inhibitors, up to thrombin time of bigatran , or NOAC blood concentration), we do not recommend intravenous thrombolysis. Quality of evidence for : very low, strength of recommendation: strong.
In patients with acute ischemic stroke of 4.5 hours duration, NOAC use within the last 48 hours before stroke onset, and anti-Xa activity 0.5 U/ml (for factor Xa inhibitors) or thrombin time 60 seconds (for direct thrombin inhibitors), there is insufficient evidence to make evidence-based recommendations. See the expert consensus statement below. Quality of evidence for : very low, Strength of recommendation: -.
In patients with acute ischemic stroke lasting 4.5 hours, there is insufficient evidence to compare intravenous thrombolysis with idarumab plus alteplase compared with no intravenous thrombolysis when dabigatran is used within 48 hours before the stroke. of patients made suggestions for or against. See the expert consensus statement below. See the expert consensus statement below. Quality of evidence for : very low, Strength of recommendation: -.
Expert Consensus Statement
In patients with acute ischemic stroke of 4.5 hours duration, NOAC use within the last 48 hours before stroke onset, and anti-Xa activity 0. U/ml (for factor Xa inhibitors) or thrombin Time 60 seconds (for direct thrombin inhibitors) 7 out of 9 panel members recommended alteplase for IVT.
For patients with acute ischemic stroke of duration 4.5 hours who received dabigatran within 48 hours before stroke, 8 of 9 panel members recommended the combination of idarumab and intravenous alteplase. Thrombosis rather than simple intravenous thrombolysis.
For patients with acute ischemic stroke lasting 4.5 hours and using a factor Thrombolysis.
Potential risk factors for bleeding
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke lasting less than 4.5 hours and low platelet counts?
Recommendation: We do not recommend intravenous thrombolysis for patients with acute ischemic stroke that lasts 4.5 hours and has a known platelet count 100*109/L. Quality of evidence for : very low, strength of recommendation: weak.
In patients with acute ischemic stroke of duration 4.5 h, and in patients with unknown platelet counts before initiating intravenous thrombolysis and no reason to expect abnormal values, we recommend starting alteplase while awaiting laboratory test results. Intravenous thrombolysis. Quality of evidence for : very low, strength of recommendation: strong.
In patients with acute ischemic stroke of 4.5 hours duration and a history of recent trauma, surgery, or biopsy, does IVT with alteplase result in better functional outcomes than no IVT?
Recommendation: For patients with acute ischemic stroke of 4.5 hours duration who underwent major surgery in the previous 14 days in a noncompressible site where bleeding is likely to result in significant bleeding (e.g., abdomen, chest, skull, vascularized tissue, or aorta), we recommend against intravenous thrombolysis. Quality of evidence for : very low, strength of recommendation: strong.
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke of intracranial hemorrhage duration 4.5 hours?
Recommendation: There is insufficient evidence to make evidence-based recommendations for patients with acute ischemic stroke that lasts 4.5 hours and have a history of intracranial hemorrhage. See the expert consensus statement below. Quality of evidence for : very low, Strength of recommendation: -.
Expert Consensus Statement
In patients with acute ischemic stroke of 4.5 hours duration and a history of intracranial hemorrhage, 8 of 9 members recommended intravenous thrombolysis with alteplase in selected cases. For example, if a long time has passed since the bleeding, or there is a non-recurrent or treated underlying cause of bleeding (such as trauma, subarachnoid hemorrhage, and subsequent endovascular or surgical resection of an aneurysm, or use of Specific antithrombotic drugs)
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke of 4.5 hours duration and associated cerebral microbleeds?
Recommendation: For patients with acute ischemic stroke of duration 4.5h and cerebral microbleed burden unknown or known to be low (e.g. 10), we recommend intravenous thrombolysis with alteplase. Quality of evidence for : low, strength of recommendation: weak.
We do not recommend intravenous thrombolytic treatment for patients with acute ischemic stroke of 4.5 hours duration and whose cerebral microbleed load has been previously confirmed to be high (eg 10). Quality of evidence for : low, strength of recommendation: weak.
Expert Consensus Statement
In patients with acute ischemic stroke within 4.5 hours of stroke onset, all nine members opposed systematic screening with MRI to assess cerebral microbleed burden before making decisions about intravenous thrombolytic therapy.
In patients with acute ischemic stroke of 4.5 hours duration and associated white matter lesions, does IVT with alteplase lead to better functional outcomes than no IVT?
Recommendation: For patients with acute ischemic stroke lasting 4.5 hours and mild to moderate white matter lesions, we recommend intravenous thrombolysis with alteplase. Quality of evidence for : moderate, strength of recommendation: strong.
For patients with acute ischemic stroke that lasts 4.5 hours and has high-load white matter lesions, we recommend intravenous thrombolysis with alteplase. Quality of evidence for : low, strength of recommendation: weak.
In patients with acute ischemic stroke of 4.5 hours duration and in the presence of an unruptured cerebral aneurysm, does IVT with alteplase lead to better functional outcomes than no IVT?
Recommendation: For patients with acute ischemic stroke lasting 4.5 hours and an unruptured cerebral aneurysm, we recommend IVT with alteplase. Quality of evidence for : very low, strength of recommendation: weak.
Other conditions
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke lasting less than 4.5 hours and a history of ischemic stroke within the past three months? ?
Recommendation: There is insufficient evidence to make evidence-based recommendations for patients with acute ischemic stroke lasting 4.5 hours and patients with a history of ischemic stroke within the past three months. See the expert consensus statement below. Quality of evidence for : very low, Strength of recommendation: -.
Expert Consensus Statement
For patients with acute ischemic stroke lasting 4.5 hours and a history of ischemic stroke within the last 3 months, 9 members supported the use of Al in selected cases. Intravenous thrombolysis with Teplase, for example, if the infarct size is small, the stroke occurred for more than 1 month, or the clinical recovery is good.
In patients with acute ischemic stroke of 4.5 hours duration who had seizures at the time of stroke , does IVT with alteplase lead to better functional outcomes than no IVT?
Recommendation: For patients with acute ischemic stroke lasting <4.5>: very low, strength of recommendation: weak.
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke of 4.5 hours duration and dissection of the aortic arch, carotid artery, or intracerebral artery?
Recommendation: We do not recommend intravenous thrombolysis for patients with acute ischemic stroke lasting 4.5 hours and accompanied by aortic arch dissection. Quality of evidence for : very low, strength of recommendation: strong.
We recommend intravenous thrombolysis with alteplase in patients with acute ischemic stroke lasting 4.5 hours and isolated carotid artery dissection. Quality of evidence for : low, strength of recommendation: weak.
There is insufficient evidence to make recommendations in patients with acute ischemic stroke lasting 4.5 hours and associated intracerebral artery dissection. See the expert consensus statement below. Quality of evidence for : very low, Strength of recommendation: -.
Expert Consensus Statement
Six of the nine panel members opposed the use of intravenous thrombolysis with alteplase in patients with acute ischemic stroke lasting 4.5 hours and intracerebral artery dissection.
Does IVT with alteplase lead to better functional outcomes than no IVT in patients with acute ischemic stroke of 4.5 hours duration who have had a myocardial infarction within the past 3 months?
Recommendation: We recommend against IVT in patients with acute ischemic stroke lasting 4.5 hours and a history of subacute (6 hours) ST-segment elevation myocardial infarction within the past 7 days. Quality of evidence for : very low, strength of recommendation: weak.
There is insufficient evidence to make recommendations for patients with acute ischemic stroke who have a duration of 4.5 hours and a history of ST-segment elevation myocardial infarction for more than 1 week to 3 months. See the expert consensus statement below. Quality of evidence for : very low, Strength of recommendation: -.
We recommend intravenous thrombolysis with alteplase in patients with acute ischemic stroke lasting 4.5 hours and in patients with a history of non-ST-segment elevation myocardial infarction within the last 3 months. Quality of evidence for : very low, strength of recommendation: weak.
Expert consensus statement
For patients with acute ischemic stroke lasting 4.5 hours and a history of ST-segment elevation myocardial infarction lasting more than one week to three months, 9 members recommended IVT with alteplase in specific circumstances . Variables to be considered are the size of the myocardial infarction, whether the myocardial infarction was treated with recanalization, and echocardiographic findings.
Among patients with acute ischemic stroke of 4.5h duration and infective endocarditis, do patients who receive IVT with alteplase have better functional prognosis than those who do not receive IVT?
Recommendation: We recommend against intravenous thrombolytic therapy in patients with acute ischemic stroke lasting 4.5 hours and definite or suspected infective endocarditis. Quality of evidence for : low. Recommendation strength: strong.
