Combining Intravenous Thrombolysis and Antithrombotic Agents in Stroke: An Update

U p until 2015, only intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) had proven to be effective for the treatment of ischemic stroke within 4.5 hours of the onset of symptoms. Intravenous thrombolysis nonetheless has certain limitations linked to the risk of causing intracerebral hemorrhage and to an insufficient rate of cerebral arterial recanalization, particularly in case of a proximal occlusion. Furthermore, 15% of patients exhibit a secondary clinical deterioration that may be caused by reocclusion after an effective thrombolysis that restored blood flow. Mechanical thrombectomy, in association with intravenous thrombolysis, represents a therapeutic revolution that has been validated by several randomized trials in acute ischemic stroke related to a carotid or a proximal middle cerebral artery occlusion. However, other intravenously administered therapeutic approaches might be used in case of a distal arterial occlusion or when the patient is admitted to a hospital that is not capable of delivering endovascular therapy. Thus, novel therapeutic strategies for ischemic stroke are undergoing evaluation, such as the association of thrombolysis by intravenous rtPA and an antithrombotic agent, with the aim of improving the rate and speed of recanalization and reducing the risk of reocclusion while also seeking to limit the rate of intracerebral hemorrhage. By way of comparison, in case of myocardial infarction, the combined administration of thrombolytic, anticoagulant, and antiplatelet agents is frequently used, with a proven favorable effect on reperfusion and clinical outcome. The aim of this review is to present the current state of knowledge regarding the addition of antithrombotic agents to intravenous thrombolysis for acute ischemic stroke treatment, with the aim of enhancing the efficacy of the treatment.