Thrombolytic Therapy in Acute Ischemic Stroke: Consensus Statements, Insights, and National Clinical Practice Perspectives from the Turkish Stroke Expert Panel

Intravenous thrombolytic therapy (IVT) remains a foundational component in the management of acute ischemic stroke, utilized either as a standalone treatment or in combination with mechanical thrombectomy (MT).Over the past decade, clinical research has broadened the therapeutic landscape to include alternative thrombolytic agents administered across extended time windows, in some cases up to 24 hours, and for varied clinical indications.This evolution marks a clear departure from the historical reliance on alteplase within the narrow 4.5-hour treatment window, ushering in a new paradigm characterized by multi-agent flexibility, time-adjusted protocols, and indication-specific strategies.This guideline initiative was undertaken to systematically review recent high-quality evidence and propose updates to thrombolysis practices within Trkiye's stroke care framework.All phase 3 randomized controlled trials published in the past decade addressing "stroke" and "thrombolysis" were included.Employing the GRADE methodology, the evidence base was rigorously appraised.Where feasible, recommendations were grounded in direct evidence; where gaps persisted, meta-analyses of case-control studies and structured expert consensus were used.Overall, the quality of evidence supporting recommendations was determined to be high.An eight-member expert panel addressed 19 clinical questions spanning eight core PICO domains, resulting in 30 formal recommendations.Full consensus was reached on all but two items.Notably, tenecteplase at a dose of 0.25 mg/kg was unanimously favored over alteplase, based on its demonstrated non-inferiority and greater ease of administration.The most debated recommendations pertained to the preference for alteplase in mismatch positive (penumbral) patients lacking thrombectomy access, and the omission of IVT when groin puncture is feasible within 30 minutes, both of which were rejected by a 75% majority.Tailoring stroke treatment through individualized patient assessment remains essential.Further randomized controlled trials are needed to better define the role of thrombolysis in relation to mechanical thrombectomy-whether administered before, during, or after the intervention.Tenecteplase, in particular, offers encouraging potential to advance stroke outcomes within the context of Trkiye's clinical landscape.Key words: Tenecteplase, alteplase, plasminogen