Brain pathways symbolizing stroke treatment balance.

Endovascular Therapy: Not a Barrier to Effective Stroke Thrombolysis?

Soraya Malik in Health & Wellness September 2025 • 4 min read.

"Discover how endovascular stroke treatment complements, not hinders, high thrombolysis rates for acute ischemic stroke patients."

For decades, intravenous recombinant tissue plasminogen activator (IVRTPA) has been the gold standard for acute ischemic stroke (AIS) treatment. Now, with advancements in endovascular stroke treatment (EST), it's crucial to understand how these approaches can work together to optimize patient outcomes.

A recent study conducted at a German academic stroke center sheds light on the impact and significance of IVRTPA in the age of modern EST. The study meticulously analyzed the clinical practice of systemic thrombolysis, evaluating its benchmarks in a setting where EST is readily available. This is vital for stroke centers worldwide aiming to refine their treatment protocols.

The core intent of this research is to demonstrate that high thrombolysis rates, achieved through IVRTPA, are not precluded by the availability of EST. By examining key metrics like door-to-needle times and rates of symptomatic intracranial hemorrhage, the study provides a roadmap for maintaining effective systemic thrombolysis programs, even as endovascular options expand.

Balancing Endovascular and Thrombolytic Stroke Therapies: Key Findings

Brain pathways symbolizing stroke treatment balance.

The retrospective observational cohort analysis included 1,034 patients with suspected AIS presenting at the emergency department in 2014. The study focused on baseline characteristics, reperfusion procedures, IVRTPA eligibility, clinical outcomes, symptomatic intracranial hemorrhage (sICH), and mortality. The study's findings offer critical insights into current stroke treatment efficacy:

The study revealed a delicate balance between EST and IVRTPA, highlighting that a substantial proportion of patients still benefit significantly from IVRTPA, either as a standalone treatment or as a bridge to endovascular intervention.

In 69% of patients, a symptomatic AIS diagnosis was confirmed.
Of those presenting within 4.5 hours of symptom onset, 62% received reperfusion therapy.
The effective thrombolysis rate, after excluding cases with absolute contraindications for IVRTPA, reached an impressive 82%.
Notably, sICH occurred in only 1.1% of patients treated with IVRTPA alone, demonstrating a safe profile when administered appropriately.
The median door-to-needle (DTN) interval was just 30 minutes, showcasing the efficiency of the stroke center's protocols.

Despite the availability of EST, a notable 17% of non-EST eligible AIS patients presenting within the critical 4.5-hour window did not receive IVRTPA, primarily due to mild or regressive symptoms. Importantly, most of these untreated patients (82%) still achieved a good clinical outcome, underscoring the importance of careful patient selection and monitoring.

Implications for Stroke Care in the Era of Advanced Therapies

This research reinforces the continued importance of IVRTPA as a frontline treatment for AIS, even in centers equipped with advanced endovascular capabilities. The key is to optimize the entire stroke care pathway, from rapid diagnosis and assessment to efficient IVRTPA administration and judicious selection of patients for EST.

The study emphasizes that high thrombolysis rates and favorable outcomes are achievable with a focus on streamlined protocols, dedicated stroke teams, and careful adherence to established guidelines. Moreover, it highlights the need for ongoing education and training to ensure that all eligible patients receive timely and appropriate reperfusion therapy.

Ultimately, the successful integration of IVRTPA and EST requires a multidisciplinary approach that prioritizes patient safety, efficiency, and evidence-based decision-making. By embracing this holistic strategy, stroke centers can maximize the benefits of both treatment modalities and improve outcomes for patients with acute ischemic stroke.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1111/ene.13831, Alternate LINK

Title: Endovascular Stroke Treatment Does Not Preclude High Thrombolysis Rates

Subject: Neurology (clinical)

Journal: European Journal of Neurology

Publisher: Wiley

Authors: S. Feda, O. Nikoubashman, K. Schürmann, O. Matz, S. C. Tauber, M. Wiesmann, J. B. Schulz, A. Reich

Published: 2018-11-18

Everything You Need To Know

What is intravenous recombinant tissue plasminogen activator (IVRTPA), and why is it important in treating stroke?

Intravenous recombinant tissue plasminogen activator (IVRTPA) is a medication that dissolves blood clots, restoring blood flow to the brain in acute ischemic stroke (AIS) patients. For decades, it has been the primary treatment, often referred to as the gold standard. Administering IVRTPA within the critical time window, usually within 4.5 hours of symptom onset, is crucial for improving outcomes. It's significance lies in its ability to quickly address the immediate threat to brain tissue, making it a crucial element in the early stages of stroke management. However, it's essential to consider that there are contraindications. It's not suitable for all stroke patients due to potential risks like symptomatic intracranial hemorrhage (sICH).

What is endovascular stroke treatment (EST), and what is its significance in stroke care?

Endovascular stroke treatment (EST) is a minimally invasive procedure where doctors use catheters to physically remove blood clots from the brain. It is an advanced treatment option for AIS. EST is especially beneficial when IVRTPA alone is insufficient or when the clot is in a large vessel. Its importance lies in providing a direct mechanical approach to restoring blood flow, particularly for patients with severe strokes. The main implications include the need for specialized expertise and equipment, which are not available in all hospitals. It is not a replacement for IVRTPA, but often used in conjunction or as a bridge treatment, depending on the patient's specific condition and the stroke center's protocols.

What is the significance of the door-to-needle (DTN) interval in stroke treatment?

The door-to-needle (DTN) interval is the time from when a patient arrives at the hospital to when IVRTPA is administered. It's a critical metric in acute stroke care because rapid treatment is essential for improving patient outcomes. A shorter DTN interval indicates a more efficient stroke care pathway, from rapid diagnosis to timely administration of IVRTPA. The significance of the DTN interval is that every minute saved can lead to better outcomes for patients. The study revealed a median DTN interval of 30 minutes, showcasing the efficiency of the stroke center's protocols, implying that prompt and coordinated efforts are paramount for effective stroke treatment.

What is symptomatic intracranial hemorrhage (sICH), and why is it a concern in stroke treatment?

Symptomatic intracranial hemorrhage (sICH) is a serious complication of stroke treatment, where bleeding occurs in the brain. The risk of sICH is a concern with IVRTPA, as it increases the risk of bleeding. The study indicated that the incidence of sICH was low at 1.1% in the study when IVRTPA was administered appropriately. Its importance is that it highlights the safety profile of IVRTPA when administered correctly and also indicates that IVRTPA should not be administered to patients with absolute contraindications. This emphasizes the need for careful patient selection and adherence to established protocols to minimize the risk of this complication.

What is meant by 'thrombolysis rate,' and why is it important to stroke care?

The term 'thrombolysis rate' refers to the percentage of patients who receive thrombolytic therapy, specifically IVRTPA, within the recommended time window. Maintaining a high thrombolysis rate is crucial for ensuring that eligible patients receive timely and effective treatment for acute ischemic stroke. High thrombolysis rates, especially in the context of available EST, mean that more patients have access to the benefits of early intervention. The study demonstrates that high thrombolysis rates are achievable even with the availability of advanced endovascular treatments. The implications of this are significant because it means that the initial stages of stroke treatment, especially in the critical time window, should include IVRTPA to improve outcomes for a larger group of patients.