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General Supportive Early Management
4.6.3. Extended Time Windows for Intravenous Thrombolysis
COR LOE
Recommendations
2a B-R
1. In patients with AIS who (a) have unknown time of onset
and are within 4.5 hours from symptom recognition and
(b) have an MRI-DWI lesion smaller than one-third of the
MCA territory and no marked signal change on FLAIR, IVT
administered within 4.5 hours of stroke symptom recognition
can be beneficial to improve functional outcomes.
2a B-R
2. (New and of High Impact) In patients with AIS who have
salvageable ischemic penumbra detected on automated
perfusion imaging and who (a) awake with stroke symptoms
within 9 hours from the midpoint of sleep or (b) are
4.5–9 hours from last known well, IV thrombolysis may be
reasonable to improve functional outcomes.
2b B-R
3. In patients with AIS due to LVO with salvageable ischemic
penumbra, presenting within 4.5 to 24 hours from symptom
onset or last known well, and who cannot receive EVT,
treatment with IVT directed by individuals with expertise
in thrombolytic stroke care may be beneficial to improve
functional outcomes.
4.6.4. Other IV Fibrinolytics and Sonothrombolysis
COR LOE
Recommendations
Other IV Fibrinolytics
2b B-R
1. In eligible patients with AIS presenting within 4.5 hours from
last known normal and not undergoing EVT, IV reteplase,
instead of alteplase, may be considered to increase the odds of
excellent functional outcome at 90 days.
2b B-R
2. In eligible patients with AIS within 4.5 hours from last
known normal and not undergoing EVT, IV mutant
prourokinase, instead of alteplase, may be considered due
to lower odds of bleeding and noninferiority for odds of
excellent functional outcome at 90 days.
3: No
benefit
A
3. In eligible patients with AIS presenting within 3 to 9 hours
from last known normal, IV desmoteplase is not recommended
for improving functional independence at 90 days.
3: No
benefit
B-R
4. In eligible patients with AIS within 4.5 hours from last known
normal, IV mutant prourokinase in conjunction with low-dose
alteplase is not recommended to improve functional outcomes.
