New Recommendations for Intravenous Thrombolysis in the Treatment of Acute Ischemic Stroke – ESO Guidelines 2021

Intravenous thrombolysis remains a cornerstone in the treatment of acute ischemic stroke (AIS). Proper patient selection and timely treatment are crucial. The ESO recommendations for the administration of alteplase can be summarized as follows:

• Alteplase is recommended if treatment can be initiated within 4.5 hours of the first symptoms of AIS. Disabling symptoms must be present at the time of treatment. The patient's age does not matter.
• In cases where the first symptoms of AIS occur 4.5–9 hours prior or are discovered upon waking, patient selection for alteplase administration should first involve MRI or CT examination.
• Low-dose alteplase, the addition of ultrasonographic augmentation to alteplase, or the administration of antiplatelet medication within the first 24 hours are not recommended as they do not increase the probability of survival without disability.
• If alteplase can be used in the treatment of AIS, it should be administered even in patients with diabetes, high blood pressure, a history of stroke or myocardial infarction, antiplatelet therapy or acetylsalicylic acid treatment, high blood sugar, seizure, or carotid artery dissection at the time of stroke, where imaging shows unruptured aneurysm or < 10 sites of brain microbleeds, white matter damage, or brain hemorrhage from a cause not likely to recur.
• Alteplase is not recommended for patients with AIS who are on warfarin or direct oral anticoagulants (DOACs). The exceptions are warfarin therapy with INR < 1.7 or DOACs, if the last dose was given ≥ 48 hours prior.
• Alteplase administration is not recommended for patients who have recently undergone major surgery, sustained significant trauma, or have endocarditis or aortic dissection.
• Alteplase can be safely administered if blood pressure is < 185/110 mmHg.

These are recommendations from the ESO working group based on a systematic literature review and meta-analysis of data with an assessment of evidence quality. These recommendations are not fully aligned with the SPC of the product yet.

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Source:

Berge E., Whiteley W. et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021 Mar; 6 (1): I–LXII, doi: 10.1177/2396987321989865.