Is thrombolysis given in both ischemic and hemorrhagic strokes?

Thrombolysis in Stroke: Ischemic vs. Hemorrhagic

Thrombolysis is only indicated for ischemic stroke and is absolutely contraindicated in hemorrhagic stroke due to the risk of worsening bleeding and increased mortality. 1

Ischemic Stroke and Thrombolysis

Intravenous (IV) Thrombolysis

• IV recombinant tissue plasminogen activator (rtPA) is recommended for acute ischemic stroke within 3 hours of symptom onset (Grade 1A recommendation) 1
• IV rtPA may be given up to 4.5 hours after symptom onset, though with less robust evidence (Grade 2C recommendation) 1
• IV rtPA is not recommended beyond 4.5 hours from symptom onset (Grade 1B recommendation) 1
• The standard dose is 0.9 mg/kg, with 10% given as bolus and the remainder infused over 60 minutes 1
• IV thrombolysis carries a 6.4% risk of symptomatic intracranial hemorrhage, which is 10 times higher than placebo (0.6%) 1

Intraarterial (IA) Thrombolysis

• IA thrombolysis may be considered for selected patients with large vessel occlusions, particularly when IV thrombolysis is contraindicated or the time window for IV treatment has passed 1
• IA thrombolysis achieves higher recanalization rates (approximately 70%) compared to IV thrombolysis (approximately 34%) for major cerebrovascular occlusions 1
• The risk of symptomatic brain hemorrhage with IA thrombolysis is approximately 8.3% in the carotid territory and 6.5% in the vertebrobasilar territory 1
• Most centers use rtPA for IA thrombolysis, although this specific application has not been directly tested in clinical trials 1

Hemorrhagic Stroke and Thrombolysis

• Thrombolysis is absolutely contraindicated in hemorrhagic stroke 1
• Hemorrhagic stroke accounts for approximately 20% of all strokes 1
• Administration of thrombolytic agents in hemorrhagic stroke would worsen bleeding and increase mortality 1
• Prior to administering thrombolysis, brain imaging (CT or MRI) is mandatory to rule out hemorrhagic stroke 1

Risk Factors for Hemorrhagic Complications After Thrombolysis

• Advanced age (especially >75 years) 1
• Higher baseline stroke severity (NIHSS score >20) 1
• Early CT changes of infarction involving more than one-third of the MCA territory 1
• Elevated blood pressure (>185/110 mmHg) 1
• Hyperglycemia (blood glucose >200 mg/dL) 1
• Prior history of stroke 1
• Small vessel disease markers (white matter hyperintensities and cerebral microbleeds) 2

Clinical Pitfalls and Caveats

• Misdiagnosis of stroke type (ischemic vs. hemorrhagic) is a critical error that can lead to inappropriate treatment 1
• Always obtain brain imaging before initiating thrombolysis to exclude hemorrhage 1
• The therapeutic window for IV thrombolysis is narrow (up to 4.5 hours), requiring urgent evaluation and treatment 1
• Remote intracerebral hemorrhage (bleeding distant from the infarct site) can occur in approximately 3.2% of patients receiving thrombolysis for ischemic stroke 2
• Patients with large vessel occlusions may benefit more from mechanical thrombectomy than thrombolysis alone, especially when presenting late 1
• Stroke mimics (such as migraine, seizures, or Bell's palsy) should be ruled out before administering thrombolysis 1

In summary, thrombolysis is a treatment specifically for ischemic stroke and must never be given in hemorrhagic stroke. The decision to administer thrombolysis requires rapid clinical assessment, neuroimaging to confirm ischemic stroke and exclude hemorrhage, and careful consideration of the time window and contraindications.