2022 Brief Practice Update on Intravenous Thrombolysis Before Thrombectomy in Patients With Large Vessel Occlusion Acute Ischemic Stroke: A Statement from Society of Vascular and Interventional Neurology Guidelines and Practice Standards (GAPS) Committee

BACKGROUND: The Society of Vascular & Interventional Neurology Guidelines and Practice Standards committee established the "Brief Practice Update" format to provide up-to-date recommendations on focused clinical topics with emerging clinical trial results. For our inaugural Brief Practice Update, we review current evidence and provide recommendations for administering intravenous thrombolysis before mechanical thrombectomy; combination therapy (mechanical thrombectomy plus intravenous thrombolysis) versus stand-alone mechanical thrombectomy approach in acute ischemic stroke secondary to emergent large vessel occlusion. METHODS: The Society of Vascular & Interventional Neurology Guidelines and Practice Standards committee members formed a writing group to review results of the most recent clinical trials of pre-mechanical thrombectomy intravenous thrombolysis. The group summarized recent clinical data to provide recommendations for clinical practice. Brief Practice Update recommendations were vetted by the Guidelines and Practice Standards quality committee to ensure adherence to Society of Vascular & Interventional Neurology standard evaluation of evidence and endorsement was obtained following formal review by the Board of Directors. RESULTS: We present a focused review of recently published clinical trials and a meta-analysis of combination intravenous thrombolysis and mechanical thrombectomy versus a stand-alone direct-to-mechanical thrombectomy treatment approach in ischemic stroke patients with emergent large vessel occlusion. Level of evidence and class of recommendation were vetted by the Guidelines and Practice Standards committee. CONCLUSIONS: We share general recommendations on pre-mechanical thrombectomy thrombolysis, using analysis of available evidence from recent randomized clinical trial data. Recommendations provided by the Society of Vascular & Interventional Neurology Brief Practice Update are not intended to replace an individualized approach to clinical decision making and patient care.