Can thrombolysis be performed in a patient with a cardioembolic stroke?

From the Guidelines

Yes, cardioembolic strokes can be treated with thrombolysis, specifically using intravenous recombinant tissue plasminogen activator (IV rtPA, alteplase) at a dose of 0.9 mg/kg (maximum 90 mg) with 10% given as a bolus and the remainder infused over 60 minutes. Treatment must be initiated within 4.5 hours of symptom onset for most patients, as suggested by the guidelines update from the American Heart Association/American Stroke Association 1. Before administering thrombolysis, a non-contrast CT scan must be performed to rule out hemorrhage, and the patient should meet eligibility criteria including no recent major surgery, no active bleeding, blood pressure <185/110 mmHg, and no use of anticoagulants with elevated INR. For patients with atrial fibrillation (a common cause of cardioembolic stroke), anticoagulation should be delayed for at least 24 hours after thrombolysis. In severe cardioembolic strokes with large vessel occlusion, mechanical thrombectomy may be considered in addition to thrombolysis if the patient presents within 24 hours and has salvageable brain tissue. Thrombolysis works by converting plasminogen to plasmin, which breaks down the fibrin in the clot, potentially restoring blood flow and limiting the extent of brain damage. The subtype of ischemic stroke, such as cardioembolism, does not influence responses to treatment with rtPA, as found by Hsia et al 1. Intraarterial administration of thrombolytic agents has considerable appeal, but no evidence is available to show that intraarterial thrombolysis is superior to intravenous treatment, as stated in the guidelines update from the American Heart Association/American Stroke Association 1. Some key points to consider when treating cardioembolic strokes with thrombolysis include:

• The importance of urgent evaluation and treatment, as stroke should be approached as a life-threatening emergency 1
• The need for a regional or local organized program to expedite stroke care, which can increase the number of patients who can be treated 1
• The use of intravenous rtPA, which is strongly recommended for treatment of carefully selected patients who can receive the medication within 3 hours of onset of stroke, with a potential extension to 4.5 hours in some cases 1
• The consideration of mechanical thrombectomy in addition to thrombolysis for severe cardioembolic strokes with large vessel occlusion, if the patient presents within 24 hours and has salvageable brain tissue.

From the Research

Thrombolysis in Cardioembolic Stroke

Thrombolysis can be a treatment option for patients with acute ischemic stroke, including those with cardioembolic stroke. The decision to perform thrombolysis should be based on careful patient selection and consideration of the potential benefits and risks.

Eligibility Criteria

According to the study by 2, thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) is approved for treatment of acute ischemic stroke, but its use is limited to eligible patients who can be treated within 3 hours of symptom onset. The study by 3 also emphasizes the importance of limiting thrombolytic therapy to carefully selected patients within established protocols.

Safety and Efficacy

The study by 4 suggests that mechanical thrombectomy may be a safe and effective treatment option for patients with cardioembolic stroke who are ineligible for intravenous thrombolysis. The study by 5 aims to evaluate the efficacy and safety of mechanical thrombectomy for cardioembolic stroke, and preliminary evidence suggests that it may be a promising treatment option.

Key Considerations

• Patient selection: Thrombolysis should only be performed in carefully selected patients who meet established eligibility criteria.
• Time window: The decision to perform thrombolysis should be made within a limited time window, typically within 3-4.5 hours of symptom onset.
• Treatment options: Mechanical thrombectomy may be a safe and effective treatment option for patients with cardioembolic stroke who are ineligible for intravenous thrombolysis.
• Benefits and risks: The potential benefits and risks of thrombolysis should be carefully considered, including the risk of intracranial hemorrhage.

Potential Benefits

• Improved outcomes: Thrombolysis may improve outcomes for patients with acute ischemic stroke, including those with cardioembolic stroke.
• Reduced disability: Thrombolysis may reduce disability and improve functional independence for patients with acute ischemic stroke.
• Increased treatment options: Mechanical thrombectomy may provide an additional treatment option for patients with cardioembolic stroke who are ineligible for intravenous thrombolysis.

Some key points to consider when evaluating the use of thrombolysis in cardioembolic stroke include:

• The patient's eligibility for thrombolysis based on established criteria
• The potential benefits and risks of thrombolysis, including the risk of intracranial hemorrhage
• The availability of mechanical thrombectomy as a treatment option for patients who are ineligible for intravenous thrombolysis
• The importance of careful patient selection and consideration of the potential benefits and risks of thrombolysis, as emphasized by studies such as 2, 4, and 3.