CRAO is a subtype of acute ischemic stroke leading to severe visual loss. Conventional management is not effective and potentially harmful. 2021 American Heart Association scientific statement proposes similar time-windows for thrombolysis in CRAO and cerebral strokes (4.5hours for IVT, 6hours for IAT).

We retrospectively identified consecutive CRAO patients that received IVT or IAT in our academic enterprise stroke centers (1997-2022). Demographic, clinical characteristics, thrombolysis timeline, concurrent CRAO therapies, hospital complications, and follow-up visual outcomes were collected and analyzed using descriptive statistics.

Of 563 CRAO admissions, 20 (3.55%) received thrombolytic therapy: 13 IVT (mean age 68, range 55-82, 61.5% male, 12 alteplase and 1 tenecteplase, all embolic etiology) and 7 IAT (mean age 55, range 17-83, 85.7% male, 4 post-operative and 3 embolic). 11/20 (55%) received additional therapies (ocular massage, intraocular pressure lowering drops, diuretics, intra-arterial verapamil). 1 CRAO mimic received IVT. Median visual loss to IVT was 158 minutes (range 67-260 min). Baseline mean logMAR visual acuity (VA) was -3.11 (±1.16). 8/13 IVT had 3-month follow-up VA recorded (mean VA -2.53). 50% improved at least one Snellen line, 12.5% had VA > 20/100. 1/13 (7.6%) had intracranial hemorrhage after IVT. Median visual loss to IAT was 335 minutes (131 minutes to 20 hours). Dose range was 5-30 mg. Baseline IAT mean logMAR VA was -3.5 (±1.19). 5/7 showed VA improvement. 1/7 had profuse epistaxis after IAT.

The management of acute CRAO in a multi-site academic stroke center remains heterogeneous, consultant specific. Most received a combination of thrombolytic and other conventional therapies, hence thrombolysis-specific outcomes could not be described. Prospective studies comparing thrombolysis and placebo are warranted to guide hyperacute CRAO practice.