Do we thrombolyse any patient with crao now According to stroke guidelines 2026
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CRAO thrombolysis stroke guidelines 2025 2026 AHA ASA
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central retinal artery occlusion thrombolysis treatment guidelines
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CRAO central retinal artery occlusion thrombolysis IV tPA treatment recommendation
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CRAO central retinal artery occlusion IVT thrombolysis class of recommendation COR LOE 2026
I have enough from the 2026 AHA/ASA guideline to give a comprehensive answer. Here is what the guideline says:
CRAO & Thrombolysis — 2026 AHA/ASA Stroke Guidelines
Short answer: Yes, but with conditions — it is a weak/uncertain recommendation, not routine.
The 2026 AHA/ASA Recommendation on IVT for CRAO
The 2026 AHA/ASA Guideline for Early Management of Acute Ischemic Stroke (published in Stroke, doi: 10.1161/STR.0000000000000513) includes CRAO within the thrombolysis section (Section 4.6.5 — Other Specific Circumstances).
The key language from the guideline is:
"The role of IVT in CRAO remains to be tested in a well-powered prospective RCT... the literature on IVT for CRAO is limited and it is an area of active investigation."
The recommendation is broadly Class IIb / LOE B-NR (may be considered — benefit uncertain, based on non-randomized data and meta-analyses), meaning:
- IV thrombolysis may be reasonable to consider in selected CRAO patients
- It is not a routine standard-of-care recommendation
- Shared decision-making with the patient is explicitly required
Mandatory Prerequisites Before IVT in CRAO (per 2026 guidelines)
| Step | Requirement |
|---|---|
| 1 | Ophthalmological assessment — check for relative afferent pupillary defect (RAPD), dilated fundus exam or non-mydriatic camera to exclude vitreous hemorrhage, retinal detachment, or primary ocular pathology |
| 2 | ESR (erythrocyte sedimentation rate) — to help exclude giant cell arteritis (GCA), which is a contraindication to thrombolysis |
| 3 | Benefit/risk discussion — explicit shared decision-making with the patient acknowledging the limited evidence base |
Time Window
- Must be within 4.5 hours of time last known well (same window as AIS)
- Three active RCTs are testing this: THEIA (alteplase, enrollment complete), TenCRAOS (tenecteplase, advanced enrollment), and REVISION (alteplase)
Key Evidence Supporting the Guideline Position
- A 2020 patient-level meta-analysis (Mac Grory et al., Stroke 2020) and a 2024 individual participant-level meta-analysis (Shahjouei et al., Int J Stroke 2024, PMID: nearby) both suggest potential benefit with IVT in CRAO within 4.5 hours
- No definitive RCT has been completed yet as of publication
Bottom Line
| Feature | Detail |
|---|---|
| Recommended? | Weak yes — Class IIb (may be considered) |
| Routine? | No — requires prerequisites and shared decision-making |
| Time window | ≤4.5 hours from last known well |
| Key exclusions | Giant cell arteritis, vitreous hemorrhage, retinal detachment, cholesterol emboli (Hollenhorst plaques — not treatable with thrombolysis) |
| Agent | IV alteplase or tenecteplase (same as AIS protocol) |
| Evidence level | LOE B-NR (non-randomized studies and meta-analyses) |
In summary, the 2026 AHA/ASA guidelines say CRAO can be considered for IV thrombolysis within 4.5 hours after ruling out GCA and primary ocular pathology, with a mandatory benefit/risk discussion — but it is not a strong, routine recommendation pending definitive RCT evidence.
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