Thrombolysis in Acute Pontine Infarction: A Potential Game-Changer

A new study suggests that intravenous thrombolysis (IVT) with t-PA may be a breakthrough in reducing neurological deterioration (ND) in patients with acute pontine infarction. Pontine infarctions, a type of ischemic stroke affecting the brainstem, account for 7% of all ischemic strokes and pose a serious risk of neurological decline despite conventional treatments.

This new research challenges traditional hesitancy around IVT for brainstem strokes, providing strong evidence that early administration can significantly improve patient outcomes.

A High-Stakes Condition

Neurological deterioration is a critical concern in acute pontine infarction, occurring in 14% to 35% of cases within days of onset. While antiplatelet and anticoagulant therapies are standard, they often fail to prevent worsening symptoms.

The underlying mechanisms of ND include propagating thrombosis, arterial stenosis, brain edema and collateral circulation failure, leading to functional impairment.

This study examined the impact of IVT in patients with pontine infarction who received treatment within 4.5 hours of symptom onset. The findings reveal a promising role for thrombolysis in reducing neurological decline and improving functional recovery.

Compelling Evidence in Favor of IVT

Among 211 patients analyzed, 74 received IVT, while 137 did not due to concerns about bleeding risk, minor stroke severity or financial constraints. The results were striking:

• Patients who received IVT had a significantly lower incidence of ND (23.0%) compared to those who did not (37.2%) (p = 0.044).

• IVT patients started with higher National Institutes of Health Stroke Scale (NIHSS) scores at admission (median: 7 vs. 4) but had similar scores to non-IVT patients at discharge, indicating better recovery.

• Logistic regression confirmed that IVT was an independent protective factor against ND (Odds Ratio: 1.509; 95% CI: 1.250–3.034).

Addressing Safety Concerns

Despite concerns about bleeding complications, the study found no significant increase in major hemorrhagic events among IVT patients:

• Intracranial hemorrhage was rare (1.4% in IVT vs. 0% in non-IVT, p = 0.351).

• Mucocutaneous bleeding was more frequent in IVT patients (29.2% vs. 1.5%) but was mild and self-limiting.

• Only two IVT patients experienced visceral organ hemorrhage, neither of which led to life-threatening outcomes.

Changing the Narrative on Thrombolysis in Brainstem Strokes

Historically, physicians have been cautious about using IVT in brainstem infarctions due to bleeding risks and uncertainty about its efficacy. This study directly challenges that notion, showing that IVT can prevent functional decline, even in patients with initially mild symptoms.

The findings suggest that thrombolysis can effectively reduce ND in pontine infarction without increasing the risk of severe bleeding. This underscores the importance of considering IVT in eligible patients, regardless of stroke severity at onset.

Looking Ahead: Implications for Stroke Care

The results have significant implications for stroke management:

• IVT should be strongly considered in acute pontine infarction cases within the therapeutic window.

• Patients with mild symptoms should not be excluded from thrombolysis, as early intervention may prevent deterioration.

• Larger, prospective studies are needed to confirm long-term benefits and optimal treatment strategies.

Final Thoughts

This study adds to the growing body of evidence supporting thrombolysis for stroke patients, reinforcing the idea that IVT should not be withheld from pontine infarction patients solely due to location-based hesitancy.

Clinicians may need to rethink their approach to treating brainstem strokes, embracing thrombolysis as a proactive measure rather than a last resort. The evolving landscape of stroke management may soon see IVT as a cornerstone therapy in pontine infarction treatment, saving lives and preserving neurological function.

By - Eeshan Aggarwal

Reference: Chai Z, Chen W, Ye Y, Song M, Lin L, Lin D, Huang X, Chi L, Huang R. Intravenous thrombolysis prevents neurological deterioration in patients with acute pontine infarction. Frontiers in Neurology. 2025 Jan 22;16:1462372.