Do Not Use Thrombolysis For CRAO
Absolutely not appropriate outside of a rigorous experimental setting.
The “all artery occlusions can be treated with thrombolysis” scope has expanded over the years – coronary arteries, peripheral arteries, intracranial arteries – and, well, why not the central retinal artery? It is, after all, just a “stroke of the eye”. Based on its seeming equivalence to other cerebral ischemia, off-label use of thrombolysis for CRAO has spread.
Now, please stop.
This trial puts tenecteplase to the test for CRAO, with most patients treated within 3 hours and all within 4.5. There was no difference in visual outcomes between groups:
In addition, there was one case of fatal intracranial hemorrhage – a fact the authors note is similar to the ~1% risk found with thrombolysis of any minor stroke.
It remains frustrating there are no obviously efficacious treatments for CRAO, but there’s certainly no role for thrombolysis.
Do you know of a robust modern evaluation of the evidence for thrombolysis for stroke in general? There was so much debate about whether thrombolysis is effective in general for stroke, and it feels to me like those concerns have been just passed over without ever being addressed. It's not clear to me if I hear less and less about that because the debate has been resolved in the favor of thrombolysis, or if the evidence is still as shaky that thrombolytics are effective for stroke at all, but there's no further appetite for debate as thrombolytics are required, correct or not. Would appreciate your thoughts.
There never was any robust data surrounding thrombolytics for stroke. Thrombolytics were forced down everybodies throat because of feeling the need to do something about a devastating disease; It continues to propagate because of a tremendous bureaucracy (accrediting agencies, hospital funding/stroke centers, employees and EMS systems, etc) needing its continuation to exist..... None of the studies showing benefit were EVER beyond criticism or analysis and many of the studies showing harm (and the significant numbers they would have added to the pool of treated patients if allowed to continue) have been forgotten