Clinical Scorecard: Stopping Intravenous Thrombolysis for Acute Ischemic Stroke

At a Glance

Key Highlights

• Among 1,504 patients treated with IVT, treatment was discontinued after the bolus or during infusion in 23 (1.5%).

• Five patients (0.3%) had treatment interrupted and later received the full dose; 18 (1.2%) had treatment terminated prematurely and received a reduced dose.

• The leading reported reasons for discontinuation included extracranial bleeding, reassessment of acute cerebral imaging, and neurological deterioration.

• Eleven of the 23 patients with discontinued IVT (47.8%) underwent additional endovascular thrombectomy.

• EVT was more frequent in the discontinued-treatment group than in the group completing full-dose rt-PA (47.8% vs. 27.9%; p = 0.035).

Guideline-Based Recommendations

Diagnosis

• For patients presenting within 4.5 hours, the center used non-contrast CT for IVT decision-making and started IVT before supplementary CT angiography and CT perfusion.

• For unknown or extended treatment windows exceeding 4.5 hours, IVT decisions were based on multimodal CT or MR imaging.

Management

• The study reports that IVT was generally administered in accordance with international guidelines.

• For large-vessel occlusion, EVT was undertaken after an interdisciplinary decision; combined IVT and EVT was pursued whenever feasible.

• The article notes that rt-PA infusion can be discontinued at any point when serious side effects develop.

Monitoring & Follow-up

• For patients whose IVT was discontinued, the study recorded complications, including extracranial and intracranial hemorrhage, and their clinical course.

• The study defined symptomatic intracranial hemorrhage using ECASS II criteria: any intracranial hemorrhage with neurological worsening, an NIHSS increase of at least 4 points from baseline or the lowest score, or hemorrhage causing death.

Risks

• Extracranial bleeding was among the leading reported reasons for IVT discontinuation.

• Neurological deterioration and reassessment of acute cerebral imaging were also among the leading reported reasons for discontinuation.

• The supplied article excerpt does not provide the full breakdown of discontinuation reasons or complication outcomes.

Patient & Prescribing Data

Retrospective cohort of 1,504 patients with suspected acute ischemic stroke who received emergency-department rt-PA at Universitätsklinikum Erlangen, Germany, between January 2018 and March 2024.

Twenty-three patients (1.5%) had IVT interrupted or terminated after the initial bolus. Five later received the full dose; 18 received a reduced dose after premature termination. Eleven of the 23 underwent EVT.

Clinical Best Practices

• Use the treatment-window imaging approach described in the study: non-contrast CT for eligible patients presenting within 4.5 hours, and multimodal CT or MR imaging for unknown or extended windows.

• For LVO, make EVT decisions through interdisciplinary discussion and pursue combined IVT and EVT whenever feasible, as described in the center's algorithm.

• Document the reason for IVT interruption or termination and record the administered rt-PA dose and subsequent clinical course.

Related Resources & Content

1. Frontiers in Neurology — Administering Intravenous Thrombolysis for Acute Ischemic Stroke Following Recent Direct Oral Anticoagulant Use: Advancing Evidence-Based Practice

2. JAMA Network Open — Prolonged Intravenous Thrombolysis—Establishing a New Benchmark for Acute Ischemic Stroke Management

3. Frontiers in Neurology — Intravenous thrombolysis for acute ischemic stroke in the extended time window of 4.5–24 h: a systematic review and network meta-analysis of randomized controlled trials

4. Annals of Neurology — Neutrophil Extracellular Traps Inhibit Fibrinolysis During Ischemic Stroke Events

5. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association | Stroke

6. These highlights do not include all the information needed to use TNKASE safely and effectively. See full prescribing information for TNKASE. TNKase® (tenecteplase) for injection, for intravenous useInitial U.S. Approval: 2000

7. Metalyse | European Medicines Agency (EMA)

8. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke | New England Journal of Medicine

9. Tenecteplase Reperfusion therapy in Acute ischemic Cerebrovascular Events-2 - American College of Cardiology

10. Tenecteplase versus alteplase for acute stroke within 4·5 h of onset (ATTEST-2): a randomised, parallel group, open-label trial - ScienceDirect

11. Tenecteplase vs Alteplase for Patients With Acute Ischemic Stroke: The ORIGINAL Randomized Clinical Trial - PMC

12. Tenecteplase for Ischemic Stroke at 4.5 to 24 Hours without Thrombectomy | New England Journal of Medicine

13. Safety and Efficacy of Direct Thrombectomy Versus Bridging Therapy in Patients with Acute Ischemic Stroke Eligible for Intravenous Thrombolysis: A Meta-Analysis of Randomized Controlled Trials - ScienceDirect

14. Thrombolysis before Thrombectomy in Stroke — A Bridge Not Fallen | New England Journal of Medicine

15. Endovascular thrombectomy with or without intravenous thrombolysis in large-vessel ischemic stroke: an updated meta-analysis - PMC