Intravenous Thrombolysis

Intravenous thrombolysis with alteplase is the standard of care in patients with eligible acute ischemic stroke patients within 4.5 h of symptom onset. Recent multicenter studies have shown the non-inferiority of tenecteplase compared to alteplase. This has led to changes in the guidelines to consider either tenecteplase or alteplase as intravenous thrombolysis agents. In patients with large vessel occlusion, direct thrombectomy is not non-inferior to bridging (intravenous thrombolysis plus direct thrombectomy) therapy in the first 4.5 h. Intravenous thrombolysis beyond 4.5 h is being actively studied. Adjuvant antithrombotics, remote ischemic conditioning, and matrix metalloproteases are still experimental. Mobile stroke units have helped with early treatment within the golden hour of symptom onset. Furthermore, thrombolysis in the mobile stroke unit is associated with better functional outcomes and treatment with tenecteplase may be associated with lower perfusion lesions compared to alteplase.