Endovascular thrombectomy and intravenous alteplase for acute ischaemic stroke

Whether or not use of intravenous alteplase in combination with endovascular thrombectomy (EVT) improves outcomes versus EVT alone, for acute stroke patients with large vessel occlusion presenting directly to a comprehensive stroke center, is uncertain. Six randomized trials and two clinical guidelines exploring this issue were published in 2021 and 2022. The European Stroke Organisation (ESO) published a guideline that made a strong recommendation in favor of intravenous thrombolysis plus EVT over EVT alone for acute stroke patients presenting with anterior circulation large vessel occlusion and who are eligible for both treatments, while our team guideline, a study-level meta-analysis and economic analysis of all six trials suggested proceeding with thrombectomy alone without intravenous alteplase. Here, we synthesized this evidence and discuss the difference between the two guidelines. In the future, more effective intravenous drug therapies are needed.