What is the management approach for acute ischemic stroke when alteplase (tissue plasminogen activator) is not available?

Management of Acute Ischemic Stroke When Alteplase is Unavailable

When alteplase is not available, proceed directly to endovascular therapy (EVT) for eligible patients with large vessel occlusion, as mechanical thrombectomy alone remains highly effective and is the only other evidence-based reperfusion option that directly reduces mortality and disability. 1, 2

Immediate Assessment and Triage

Rapidly determine EVT candidacy through:

• Non-contrast CT scan to exclude hemorrhage (takes <5 minutes, 3 mSv radiation dose) 1, 3
• CT angiography to identify vessel occlusion location (large vessel occlusions include internal carotid artery, M1, M2, and basilar artery) 1
• NIHSS score assessment - scores ≥6 suggest large vessel occlusion with 87% sensitivity 4
• Pre-stroke functional status (mRS 0-2) to establish baseline 1

Direct Endovascular Therapy Approach

For patients with confirmed large vessel occlusion:

• Combined stent-retriever and aspiration technique (BADDASS approach) achieves the fastest first-pass complete reperfusion and should be the standard method 1
• Time windows for EVT extend to 6-24 hours with appropriate imaging selection, far beyond the 4.5-hour alteplase window 3
• Every 30-minute delay decreases good functional outcome probability by 8-14%, making speed critical even without alteplase 1, 2, 4

Alternative Thrombolytic Agent: Tenecteplase

If any thrombolytic agent is available as an alternative:

• Tenecteplase demonstrates better functional outcomes compared to alteplase in patients undergoing EVT, with improved fibrin-specificity, longer half-life, and single bolus administration 1
• Dosing is simpler than alteplase (single bolus vs. bolus plus infusion) 1
• Consider tenecteplase if available at your institution, as it may soon replace alteplase as the standard thrombolytic 1

Management Without Any Reperfusion Therapy

For patients ineligible for EVT or when EVT is unavailable:

• Aspirin 160-325 mg should be initiated within 48 hours of symptom onset (strong Grade 1A recommendation) 2
• Blood pressure management: Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg 2, 3
• VTE prophylaxis: Initiate prophylactic-dose LMWH or intermittent pneumatic compression within 24 hours 2
• Early rehabilitation: Begin within 24 hours if no contraindications, with initial assessment by rehabilitation professionals within 48 hours 2

Critical Pitfalls to Avoid

Do not delay EVT waiting for alteplase to become available - direct EVT is effective and every minute counts, with 8-14% reduction in good outcomes per 30-minute delay 1, 2, 4

Do not use overly restrictive EVT selection criteria - the American College of Cardiology recommends asking "which patients should NOT be treated?" rather than narrowly defining who qualifies, as undertreatment causes more harm than overtreatment 1

Do not administer corticosteroids for cerebral edema - they are not recommended and osmotic therapy with hyperventilation should be used instead for deteriorating patients 2, 3

Do not use elastic compression stockings alone for VTE prophylaxis - they are ineffective in stroke patients (Grade 2B) 2

Transport Considerations

For basilar artery occlusion specifically:

• Intra-arterial thrombolysis remains an option even in longer time intervals (up to 6-12 hours) when performed at experienced stroke centers with immediate access to cerebral angiography 2
• Combined IVT and EVT is suggested over direct EVT when any thrombolytic is available and not contraindicated, even for basilar occlusions 1

Systems-Level Approach

Pre-notification and parallel processing are essential - activate the neuro-interventional team while obtaining imaging, meet the patient at CT scanner, and have a standardized angiography tray ready 1

Door-to-groin-puncture time should be minimized as the primary metric when alteplase is unavailable, replacing the traditional door-to-needle time focus 4