Bottom Line

If EVT is readily available and the patient is a candidate for this treatment modality, there does not appear to be a role for systemic thrombolysis in patients with acute ischemic stroke.

Case Resolution

You engage in shared decision making with the patient and her spouse. The decision is to hold off on administration of systemic thrombolytics and await the neurointerventional team. They arrive and take the patient for EVT, and she has a successful outcome.

Thank you to Dr. Anand Swaminathan, an assistant professor of emergency medicine at St. Joseph’s Regional Medical Center in Paterson, New Jersey, for his help with this review.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. 

References

1. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-1587.
2. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329.
3. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Use of Intravenous tPA for Ischemic Stroke: Brown MD, Burton JH, Nazarian DJ, et al. Clinical policy: use of intravenous tissue plasminogen activator for the management of acute ischemic stroke in the emergency department. Ann Emerg Med. 2015;66(3):322-333.e31.
4. Milne WK, Lang E, Ting DK, et al. CJEM debate series: #TPA should be the initial treatment in eligible patients presenting with an acute ischemic stroke. CJEM. 2020;22(2):142-148.
5. Alper BS, Foster G, Thabane L, et al. Thrombolysis with alteplase 3-4.5 hours after acute ischaemic stroke: trial reanalysis adjusted for baseline imbalances. BMJ Evid Based Med. 2020;bmjebm-2020-111386.
6. Berkhemer OA, Fransen PSS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11-20.