From the Guidelines
Alteplase is not recommended for a small acute right parietal infarct without large vessel occlusion on MRI/MRA, as the benefit of thrombolytic therapy is likely minimal and may not outweigh the risks of hemorrhagic complications. The guidelines from the American Heart Association/American Stroke Association 1 suggest that IV alteplase should not be administered to patients with acute ischemic stroke who have a low likelihood of benefiting from thrombolytic therapy. In this scenario, the patient has a small infarct without large vessel occlusion, which suggests a favorable natural history and a lower likelihood of benefiting from thrombolytic therapy.
The risk of bleeding complications, including symptomatic intracranial hemorrhage, is a significant concern when administering IV alteplase 1. The guidelines recommend that IV alteplase should not be administered to patients with a high risk of bleeding complications, including those with a history of intracranial hemorrhage, recent severe head trauma, or coagulopathy.
Instead of thrombolytic therapy, management should focus on secondary stroke prevention with antiplatelet therapy, statins, blood pressure control, and addressing modifiable risk factors such as diabetes, smoking, and atrial fibrillation 1. A comprehensive stroke workup to determine etiology is essential for guiding specific preventive strategies. Each case should be individualized, considering factors like symptom severity, time since onset, and patient comorbidities.
Some key points to consider in the management of this patient include:
- The patient's symptom severity and time since onset
- The presence of any contraindications to thrombolytic therapy
- The patient's comorbidities and risk factors for stroke
- The results of the comprehensive stroke workup to determine etiology
- The potential benefits and risks of antiplatelet therapy, statins, and other preventive strategies.
Overall, the decision to administer IV alteplase should be made on a case-by-case basis, taking into account the individual patient's characteristics and the potential benefits and risks of thrombolytic therapy.
From the Research
Alteplase Use in Acute Ischemic Stroke
- The use of alteplase in acute ischemic stroke is a well-established treatment option, with studies showing its efficacy in improving clinical outcomes 2.
- However, the decision to use alteplase in a specific patient depends on various factors, including the time of onset, severity of symptoms, and presence of large vessel occlusion.
Large Vessel Occlusion and Alteplase
- In patients with large vessel occlusion, mechanical thrombectomy is the standard of care, with or without intravenous thrombolysis 3.
- The use of alteplase in patients with large vessel occlusion is generally recommended, but the presence of small acute infarcts without visible large vessel occlusion may require a different approach.
Small Acute Infarcts without Large Vessel Occlusion
- In patients with small acute infarcts without visible large vessel occlusion, the use of alteplase may not be necessary, and dual-antiplatelet therapy may be a better option 4.
- A study comparing alteplase with dual-antiplatelet therapy in acute minor stroke found that patients treated with dual-antiplatelet therapy had better functional outcomes at 3 months 4.
Considerations for Alteplase Use
- The time of onset and severity of symptoms are crucial factors in determining the use of alteplase 2.
- Patients with mild symptoms and small infarcts may not benefit from alteplase, and the risk of intracranial hemorrhage should be carefully considered 4, 2.
- The absence of collaterals may be associated with larger infarct volume and worse outcome, and collateral score may be a useful tool in identifying patients who might benefit from mechanical thrombectomy 5.