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Thrombolytics for the Management of Acute Ischemic Stroke

Use of Thrombolytics for the Management of Acute Ischemic Stroke

Scope of Application

This guideline is intended for physicians working in emergency departments (EDs).

Inclusion Criteria

This guideline is intended for adult patients aged 18 years and older presenting to the ED with acute ischemic stroke.

Exclusion Criteria

This guideline is not intended to be used for pediatric or pregnant patients.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.

Critical Questions

  • In adult stroke patients who are a candidate for mechanical thrombectomy, is the use of intravenous thrombolytics (IVT) prior to mechanical thrombectomy (Bridge therapy) beneficial and safe versus mechanical thrombectomy alone?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    In stroke patients who are candidates for both mechanical thrombectomy and IVT*, IVT should be offered and may be given prior to mechanical thrombectomy.

    * IVT is given within 4.5 hours from symptom onset

    Level C Recommendations

    When feasible, shared decisionmaking between the patient (and/or their surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer intravenous thrombolytics (Consensus recommendation).

    Level A Recommendations

    None specified.

    Level B Recommendations

    In stroke patients who are candidates for both mechanical thrombectomy and IVT*, IVT should be offered and may be given prior to mechanical thrombectomy.

    * IVT is given within 4.5 hours from symptom onset

    Level C Recommendations

    When feasible, shared decisionmaking between the patient (and/or their surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer intravenous thrombolytics (Consensus recommendation).

Download the Policy

PDF Icon Thrombolytics for the Management of Acute Ischemic Stroke.pdf September 2024

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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