What is the standard treatment of acute ischemic stroke in the VERITAS (Vascular Endothelial Growth Factor Receptor Inhibition in Acute Ischemic Stroke) study?

Standard Treatment of Acute Ischemic Stroke in the VERITAS Study

The standard treatment for acute ischemic stroke in the VERITAS study consists of intravenous alteplase (rtPA) as first-line therapy within 4.5 hours of symptom onset, followed by endovascular therapy with mechanical thrombectomy for eligible patients with large vessel occlusions. 1

First-Line Treatment: Intravenous Thrombolysis

Intravenous Alteplase (rtPA)

• Dosage: 0.9 mg/kg (maximum 90 mg)
• Administration: 10% given as initial bolus, remainder infused over 1 hour 1
• Time window: Within 4.5 hours of symptom onset 1
• Blood pressure requirements:
  • BP must be <185/110 mmHg before initiating therapy
  • BP must be maintained <180/105 mmHg for at least 24 hours after treatment 1

Patient Selection Criteria for IV Alteplase

• Confirmed diagnosis of ischemic stroke (not hemorrhagic)
• Measurable neurological deficit
• Time of symptom onset clearly established
• No evidence of intracranial hemorrhage on non-contrast CT
• No major early ischemic changes involving more than one-third of MCA territory 1

Second-Line Treatment: Endovascular Therapy

Mechanical Thrombectomy

• Indicated for patients with large vessel occlusions (intracranial carotid artery and M1 occlusions)
• Time window: Within 6 hours of symptom onset (standard window) 1
• Preferred technique: Combined approach using stent-retrievers and aspiration (BADDASS technique - BAlloon guide with large bore Distal access catheter with Dual Aspiration with Stent-retriever as Standard Approach) 1

Patient Selection for Endovascular Therapy

• Confirmed large vessel occlusion on CT angiography
• NIHSS score ≥6 indicating moderate to severe stroke
• Pre-stroke functional independence (modified Rankin Scale score 0-1)
• Treatment can be initiated within appropriate time window 1

Imaging Protocol

• Non-contrast CT to rule out hemorrhage (mandatory)
• CT angiography to identify vessel occlusion and location
• Optional: Multiphase CT angiography or CT perfusion for patient selection in extended time windows 1

Workflow Optimization

• Door-to-needle time target: As fast as possible, ideally <60 minutes
• Consider administering alteplase directly in the CT room after excluding hemorrhage
• Keep patient on emergency stretcher instead of relocating to hospital bed to reduce delays 1

Special Considerations

• Wake-up strokes: May be eligible for treatment if favorable imaging profile is present (DWI/FLAIR mismatch on MRI) 1
• For patients ineligible for IV alteplase, proceed directly to endovascular therapy if appropriate
• Blood pressure management:
  • For patients not receiving thrombolysis with BP <220/120 mmHg, initiating antihypertensive treatment within first 48-72 hours is not effective 1
  • For neurologically stable patients with BP >140/90 mmHg, starting antihypertensive therapy during hospitalization is reasonable 1

Common Pitfalls and Caveats

• Delayed treatment significantly reduces efficacy - every 30-minute delay in recanalization decreases the chance of good outcome by 8-14% 1
• Overselection of patients using excessive imaging criteria may deny treatment to potentially eligible patients
• Symptomatic intracranial hemorrhage is the most serious complication of thrombolysis, occurring in approximately 6.4% of treated patients 1
• Patients with severe strokes (NIHSS >20) and early CT changes have increased risk of symptomatic hemorrhage 1

The VERITAS study follows these standard treatment protocols, which are based on the most recent guidelines for acute ischemic stroke management, prioritizing rapid treatment to maximize neurological recovery and minimize mortality and long-term disability.