Intravenous
thrombolysis is the only approved systemic reperfusion treatment for
patients with acute ischaemic stroke. These European Stroke Organisation
(ESO) guidelines provide evidence-based recommendations to assist
physicians in their clinical decisions with regard to intravenous
thrombolysis for acute ischaemic stroke. These guidelines were developed
based on the ESO standard operating procedure and followed the Grading
of Recommendations, Assessment, Development, and Evaluation (GRADE)
methodology. The working group identified relevant clinical questions,
performed systematic reviews and meta-analyses of the literature,
assessed the quality of the available evidence, and wrote
recommendations. Expert consensus statements were provided if not enough
evidence was available to provide recommendations based on the GRADE
approach. We found high quality evidence to recommend intravenous
thrombolysis with alteplase to improve functional outcome in patients
with acute ischemic stroke within 4.5 h after symptom onset. We also
found high quality evidence to recommend intravenous thrombolysis with
alteplase in patients with acute ischaemic stroke on awakening from
sleep, who were last seen well more than 4.5 h earlier, who have MRI
DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned.
These guidelines provide further recommendations regarding patient
subgroups, late time windows, imaging selection strategies, relative and
absolute contraindications to alteplase, and tenecteplase. Intravenous
thrombolysis remains a cornerstone of acute stroke management.
Appropriate patient selection(so cherry picking rather than having the ability to treat everyone. Hope you know enough to have the correct stroke.) and timely treatment are crucial. Further
randomized controlled clinical trials are needed to inform clinical
decision-making with regard to tenecteplase and the use of intravenous
thrombolysis before mechanical thrombectomy in patients with large
vessel occlusion.
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