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Abstract
More than 25 years have passed since the US Food and Drug Administration approved IV recombinant tissue plasminogen activator (alteplase) for the treatment of acute ischemic stroke. This landmark decision brought a previously untreatable disease into a new therapeutic landscape, providing inspiration for clinicians and hope to patients. Since that time, the use of alteplase in the clinical setting has become standard of care, continually improving with quality measures such as door-to-needle times and other metrics of specialized stroke unit care. The past decade has seen more widespread use of alteplase in the prehospital setting with mobile stroke units and telestroke and beyond initial time windows via the use of CT perfusion or MRI. Simultaneously, the position of alteplase is being challenged by new lytics and by the concept of its bypass altogether in the era of endovascular therapy. We provide an overview of alteplase, including its earliest trials and how they have shaped the current therapeutic landscape of ischemic stroke treatment, and touch on new frontiers for thrombolytic therapy. We highlight the critical role of thrombolytic therapy in the past, present, and future of ischemic stroke care.
Glossary
- AHA/ASA=
- American Heart Association/American Stroke Association;
- AIS=
- acute ischemic stroke;
- ARTSS=
- Argatroban with Recombinant Tissue Plasminogen Activator for Acute Stroke;
- ATLANTIS=
- Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke;
- BI=
- Barthel Index;
- CI=
- confidence interval;
- DRG=
- diagnosis-related group;
- DTN=
- door-to-needle;
- DWI=
- diffusion-weighted imaging;
- ECASS=
- European Cooperative Acute Stroke Study;
- EVT=
- endovascular thrombectomy;
- FDA=
- Food and Drug Administration;
- FLAIR=
- fluid-attenuated inversion recovery;
- GWTG-S=
- Get With the Guidelines–Stroke;
- IST-3=
- International Stroke Trial 3;
- LKN=
- last known normal;
- LVO=
- large vessel occlusion;
- mRS=
- modified Rankin Scale;
- MSU=
- mobile stroke unit;
- NIHSS=
- National Institutes of Health Stroke Scale;
- NINDS=
- National Institute of Neurologic Disorders and Stroke;
- OR=
- odds ratio;
- PAI-1=
- plasminogen activator inhibitor 1;
- PSC=
- primary stroke center;
- qDFM=
- quantitative diffusion-weighted imaging–fluid-attenuated inversion recovery mismatch;
- sICH=
- symptomatic intracerebral hemorrhage;
- tPA=
- tissue plasminogen activator
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received June 28, 2020.
- Accepted in final form May 26, 2021.
- © 2021 American Academy of Neurology
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