Abstract WP041: IV Thrombolysis in Cervical Artery Dissection: A Comparative Analysis of U.S. and European Guidelines and Clinical Practice Implications

Background: Thrombolysis (IV tPA) with either alteplase or tenecteplase in cervical artery dissection (CAD) remains an area of uncertainty, despite observational studies and post-hoc analyses supporting its safety and efficacy. Notably, guideline recommendations differ between the United States and Europe, potentially affecting clinical decision-making and time-to-treatment as well as clinical outcomes. Objective: To explore the approach to IV tPA administration in suspected or confirmed cervical artery dissection among stroke specialists in the Chicago Metropolitan area as well as to compare U.S. and European guidelines regarding treatment practices. Methods: We conducted a comparative review of major guideline documents including the American Heart Association/American Stroke Association (AHA/ASA) guidelines (2019 and updates) and European Stroke Organisation (ESO) guidelines. We focused on inclusion or exclusion of CAD in thrombolysis recommendations and the possible need for vascular imaging prior to treatment. We also conducted a survey among Chicago Vascular Neurologists, receiving, to date, 25 total responses, about their practice and decision making involved in acute ischemic stroke treatment. Results: AHA/ASA guidelines support thrombolysis in CAD-related stroke when standard eligibility criteria are met, without requiring confirmation of dissection prior to treatment. A regional survey of Vascular Neurologists corroborates that the decision to initiate tPA therapy is not routinely delayed pending angiographic results. There is consensus that in cases of known dissection in the intracranial segments, physicians are more cautious with the decision to administer tPA typically made after discussion with the patient or family, though treatment is not necessarily withheld. In contrast, European guidelines advise caution or delay, with some recommending CTA or MRA to exclude vascular rupture or pseudoaneurysm prior to IV tPA. These differences may lead to decreased or delayed thrombolysis in Europe. The practice variability underscores a lack of consensus on managing CAD in the hyperacute phase. Conclusion: Despite increasing evidence supporting IV tPA use in CAD-related stroke, international differences in guideline interpretation result in inconsistent practice.