Intravenous thrombolysis in ischemic stroke: 10 rules for the practical neurologist

Abstract

Intravenous thrombolysis (IT) with recombinant tissue plasminogen activator has remained the main method of reperfusion therapy in ischaemic stroke for a quarter of a century. The main trends in the use of IT in recent years are the expansion of the therapeutic window using additional methods of neuroimaging, reducing the number of contraindications and introduction into clinical practice of bolus forms of drugs. Providing IT to the largest number of patients should be considered a major challenge for the primary vascular department. This article presents 10 clinical rules for extending IT in stroke while ensuring its efficacy and safety: 1) conduct IT in suspected stroke; 2) conduct IT in patients over 80 (and even 90) years of age; 3) conduct IT in minor but disabling stroke; 4) conduct IT in minor vertebrobasilar stroke and central acute vestibular syndrome; 5) perform IT in cases of large artery occlusion; 6) perform IT in suspected lacunar stroke and chronic neuroimaging changes (lacunas, white matter hyperintensity, atrophy); 7) reduce door-to-needle time, use thrombolytics with bolus administration; 8) use neuroimaging options (CT perfusion, MR perfusion, MR DWI/FLAIR) to expand the therapeutic window; 9) ensure the safety of IT; 10) be prepared for complications. Increasing the frequency of IT should not be seen as a goal, but intensifying the use of this method of treatment is associated with the improvement of all areas of the diagnostic and treatment process in the clinic and the improvement of stroke outcomes.