Alteplase thrombolysis benefits can last up to 9 hours with perfusion imaging after stroke

Australia: Stroke thrombolysis with alteplase is currently recommended 0–4·5 h after stroke onset. Now, a recent review has found that the benefits of alteplase can extend up to 9 hours after an ischemic stroke with perfusion imaging.

Results of the study, published in the journal The Lancet demonstrated that patients with ischemic stroke 4·5–9 h from stroke onset or wake-up stroke with salvageable brain tissue (identified by perfusion imaging) who were treated with alteplase had better functional outcomes than patients on placebo.

Perfusion imaging allows the selection if stroke patients with salvageable brain tissue requiring thrombectomy up to 24 hours after symptom onset. But it is still not clear whether a similar approach would help in identifying patients who could benefit from thrombolysis beyond the current 4.5-hour time window or with stroke symptoms upon awakening.

Bruce C V Campbell, Melbourne Brain Centre, University of Melbourne, Melbourne, VIC, Australia, and colleagues conducted conducted a systematic review and individual patient-level meta-analysis to determine whether perfusion imaging can identify patients with salvageable brain tissue with symptoms 4·5 h or more from stroke onset or with symptoms on waking who might benefit from thrombolysis.

For the purpose, the researchers searched PubMed for randomised trials published in English between Jan 1, 2006, and March 1, 2019. Three trials, EXTEND, ECASS-4-EXTEND, and EPITHET, met eligibility criteria and contributed data for the 410 patients included in this analysis.

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Key findings of the study include:

• Of the 414 patients included in the three trials, 213 (51%) were assigned to receive alteplase and 201 (49%) were assigned to receive placebo.


• Overall, 211 patients in the alteplase group and 199 patients in the placebo group had mRS assessment data at 3 months and thus were included in the analysis of the primary outcome.


• 76 (36%) of 211 patients in the alteplase group and 58 (29%) of 199 patients in the placebo group had achieved excellent functional outcome at 3 months.


• Symptomatic intracerebral haemorrhage was more common in the alteplase group than the placebo group (ten [5%] of 213 patients vs one [<1%] of 201 patients in the placebo group). 29 (14%) of 213 patients in the alteplase group and 18 (9%) of 201 patients in the placebo group died.


• The rate of symptomatic intracerebral haemorrhage was higher with alteplase, but this increase did not negate the overall net benefit of thrombolysis.

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To read the complete study log on to https://doi.org/10.1016/S0140-6736(19)31053-0