The scientific session “Thrombolysis for Acute Ischemic Stroke – Exploring the Grey” provided a comprehensive exploration of the latest developments and research in thrombolytic therapy for acute ischemic stroke. Moderated by Sonia Alamowitch from Paris, France, and Simona Sacco from L’Aquila, Italy, the session featured insightful presentations from leading experts in the field, each addressing critical aspects of thrombolytic therapy.

Professor David Seiffge (Bern, Switzerland) opened the session with an enlightening presentation on the complexities of administering intravenous thrombolysis (IVT) to patients who are already on anticoagulant therapy, especially direct oral anticoagulants (DOACs). He presented recent data on more liberal decisions and observational studies that demonstrated the safety and potential efficacy of thrombolysis in this increasing subgroup. The stroke center in Bern did not experience safety issues with increasingly liberal IVT decisions in a preliminary, but reassuring analysis. Participation in the upcoming DO-IT projects is possible to overcome this main barrier to IVT. 

Professor Götz Thomalla (Hamburg, Germany) discussed the potential for extending the thrombolysis treatment window beyond the conventional limits, particularly in settings lacking advanced neuroimaging capabilities. His findings suggested that, with appropriate clinical judgment, extending the treatment window could significantly benefit patient outcomes without substantially increasing risks. Options include DWI/FLAIR mismatch in MRI centers, but more importantly also individually non-contrast CT might be enough to rule out a large baseline ischemic damage. Naturally, CT-perfusion is helpful to facilitate those borderline IVT decisions. 

Professor Christian Nolte (Berlin, Germany) focused on the interaction between IVT and cerebral small vessel disease, presenting advanced markers that could predict treatment responses. For example, although white matter disease is associated with poor prognosis and sICH, it does not modify the treatment effect of IVT and should not be a reason to withhold IVT. His research highlighted the importance of personalized IVT decision while not being afraid of imaging biomarkers of SVD.

Professor Georgios Tsivgoulis (Athens, Greece) explored the potential advantages of tenecteplase over the traditional alteplase in thrombolytic therapy. Through comparative studies, he illustrated tenecteplase’s favorable profile, including ease of administration resulting in faster time to treatment. The time has come to cross the Rubikon and transition to TNK and guidance has been laid out to do so for centers. 

Concluding the session, Professor Pooja Khatri presented innovative adjunct therapies aimed at enhancing reperfusion and preventing reocclusion following thrombolysis. She showcased emerging pharmacological strategies including Glenzocimab, Eptifibatide, Argatroban, amongst others. The recently presented ARAIS, MOST and ACTISAVE trials did not show benefit in terms of recanalization and funcitional outcome. Thus, the we have awakened from the dream of cocktail therapy for IVT. However, DNAse enhanced IVT is on the horizon and provides novel hope if efficient in upcoming trials. 

The session “Thrombolysis for Acute Ischemic Stroke – Exploring the Grey” was a resounding success, offering novel options for the greyzones of IVT stroke management. The diverse topics and expert presentations underscored the importance of ongoing innovation and tailored approaches in improving patient care.