Background: 

Acute nonarteritic central retinal artery occlusion (CRAO) is an eye stroke with poor visual prognosis and no proven effective therapies. Given advances in acute stroke care, thrombolysis in CRAO merits critical re-examination. We review the evidence for intravenous (IV) and intra-arterial (IA) tissue plasminogen activator (tPA) in CRAO management.

Evidence Acquisition: 

MEDLINE, Scopus, and Cochrane online databases were systematically searched from 1960 to present, for reports of acute IV or IA therapy with alteplase or tenecteplase in nonarteritic CRAO patients. English language case reports, case series, interventional studies, or randomized controlled trials were included. The study type, age and number of subjects, the regimen administered, the time since symptoms' onset, visual outcome, and safety reports were noted.

Results: 

Use of IV thrombolysis with alteplase was reported in 7 articles encompassing 111 patients, with 54% of them receiving IV tPA within 4.5 hours of symptom onset, and none developing symptomatic intracranial or ocular hemorrhage. Six studies described IA alteplase administration, with only 18 of a total of 134 patients (13.4%) treated within the first 6 hours after visual loss. The reported adverse events were minimal. Visual outcomes post-IV and IA thrombolysis were heterogeneously reported; however, most studies demonstrated benefit of the respective reperfusion therapies when administered very early. We found no reports of tenecteplase administration in CRAO.

Conclusions: 

In 2020, nonarteritic CRAO patients should theoretically receive the same thrombolytic therapies, in the same time window, as patients with acute cerebral ischemia. Eye stroke and teleeye stroke code encounters must include an expert ophthalmologic evaluation to confirm the correct diagnosis and to evaluate for ocular signs that may help guide IV tPA administration or IA management. Future research should focus on developing feasible retinal penumbra imaging studies that, similar to cerebral tissue viability or perfusion imaging, can be incorporated into the thrombolysis decision-making algorithm.

中文翻译：

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2020年中央视网膜动脉阻塞的溶栓治疗：时机已到！

背景： 

急性非动脉中央视网膜动脉闭塞（CRAO）是一种眼卒中，其视觉预后较差，尚无有效的疗法。鉴于急性中风护理的进步，CRAO中的溶栓治疗应进行严格的复查。我们回顾了CRAO管理中静脉（IV）和动脉内（IA）组织纤溶酶原激活剂（tPA）的证据。

取证： 

从1960年至今，系统地搜索MEDLINE，Scopus和Cochrane在线数据库，以获取非动脉CRAO患者接受阿替普酶或替奈普酶急性IV或IA治疗的报道。包括英语病例报告，病例系列，干预性研究或随机对照试验。记录研究类型，年龄和受试者人数，给药方案，自症状发作以来的时间，视觉结果和安全性报告。

结果： 

在7篇文章中报道了111名患者使用IV溶栓联合阿替普酶的情况，其中54％的患者在症状发作4.5小时内接受了IV tPA治疗，并且均未出现有症状的颅内或眼部出血。六项研究描述了IA阿替普酶的给药，总共134例患者中只有18例（13.4％）在视力丧失后的最初6小时内接受了治疗。报告的不良事件极少。IV和IA溶栓后的视觉结果异质性报道。但是，大多数研究表明，尽早使用相应的再灌注疗法是有好处的。我们在CRAO中没有发现替奈普酶给药的报道。

结论： 

到2020年，非动脉CRAO患者理论上应在与急性脑缺血患者相同的时间范围内接受相同的溶栓治疗。眼卒中和远眼卒中代码的相遇必须包括专业的眼科评估，以确认正确的诊断并评估可能有助于指导IV tPA管理或IA管理的眼部症状。未来的研究应集中在发展可行的视网膜半影成像研究上，该研究类似于脑组织生存力或灌注成像，可以纳入溶栓决策算法中。