ESOC 2018 – Future Directions on Thrombolysis

Although thrombectomy is the rising star in stroke neurology, intravenous thrombolysis (IVT) remains the most important medical therapy for the vast majority of acute ischemic stroke patients. The session, chaired by N. Wahlgren and D. Jovanovic, explored future directions of this treatment and highlighted risks and benefits in currently debated patient populations. The first speaker, N. Logallo, provided an updated review of the available evidences about the newer thrombolytic agents, desmoteplase and tenecteplase, and predicted a bright future for tenecteplase. The second speaker, J. Ferrari, discussed pros and cons of IVTin patients with mild stroke and concluded that a randomized trial (intravenous thrombolysis vs placebo) in this group of patients is warrented.  David Seiffge presented the current approach for IVT in patients on DOACs and highlighted the risk of intracranial bleeding in this population. Do patients with severe strokes still benefit from IVT? This question was positively answered by Danilo Toni: These patients benefit from IVT (but most of them need additional mechanical thrombectomy). Tenecteplase might be a viable alternative to alteplase in these patients. Finally, Götz Thomalla gave an overview of the impressive results of the WAKE-UP trial on IVT in patients with wake-up stroke and the implications for clinical practice. We predict that alteplase will soon be recommended for treatment of patients with wake-up stroke and those with stroke of unknown onset presenting with DWI-FLAIR mismatch at admission MRI.