On September 26, 2024, the ACEP Board of Directors approved a clinical policy developed by the ACEP Clinical Policies Committee on the use of thrombolytics for the management of acute ischemic stroke. This clinical policy was published in the December 2024 issue of the Annals of Emergency Medicine, can be found on ACEP’s website, and will also be included in the ECRI Guidelines Trust upon its acceptance.

Approximately 30 percent of all acute ischemic strokes have a large vessel occlusion, which contributes to 64 percent of all moderate-to-severe disability from stroke at three months and more than 95 percent of stroke deaths at six months. In the past decade, acute treatment for large vessel occlusion has expanded beyond thrombolytics with evidence supporting the use of endovascular therapy such as mechanical thrombectomy.

A recent international survey showed that 63 percent of stroke physicians consisting of neurologists, interventionalists, and neurosurgeons would still give intravenous thrombolysis prior to endovascular therapy. This practice trend may be because of conflicting consensus from experts on whether to support intravenous thrombolysis prior to endovascular therapy. This latest clinical policy from the ACEP Clinical Policies Committee is an update of the 2015 Clinical Policy on the use of tissue plasminogen activator for the management of acute ischemic stroke, and seeks to evaluate the outcomes for patients who present with an acute stroke from a large vessel occlusion who have received endovascular therapy with or without intravenous thrombolysis.

The critical question was based on feedback from ACEP membership. A systematic review of the evidence was conducted, and the committee made recommendations (Level A, B, or C) based on the strength of evidence available. This clinical policy underwent internal and external expert review, and was available for review by ACEP membership during an open comment period. Responses received were used to refine and enhance the final policy.

Critical Question

In adult stroke patients who are a candidate for mechanical thrombectomy, is the use of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (bridge therapy) beneficial and safe versus mechanical thrombectomy alone?

Patient Management Recommendations  

• Level A recommendations. None specified.
• Level B recommendations. In stroke patients who are candidates for both mechanical thrombectomy and IVT,* IVT should be offered and may be given prior to mechanical thrombectomy. (*IVT is given within 4.5 hours from symptom onset.)
• Level C recommendations. When feasible, shared decision making between the patient (and/or their surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer intravenous thrombolytics (consensus recommendation).

More on ACEP’s Class of Evidence framework and Recommendation Levels can be found at www.acep.org/patient-care/clinical-policies.

Dr. Lo is chief of emergency medicine at Sentara Norfolk General Hospital and professor at Eastern Virginia Medical School. He is the subcommittee chair for ACEP’s Stroke Clinical Policy, and a partner at Emergency Physicians of Tidewater in Norfolk, Va. When he’s not working, he enjoys eating small portions on large plates.