Key result
IV thrombolysis at 4.5-24 hours improves functional recovery in imaging-selected stroke despite increased sICH risk.
Why the study?
Intravenous thrombolysis is standard within 4.5 hours of acute ischemic stroke onset, but the efficacy and safety of treatment beyond 4.5 hours using imaging-based selection remain unclear.
Does intravenous thrombolysis with alteplase or tenecteplase improve functional outcomes in patients with acute ischemic stroke 4.5-24 hours after onset when selected by imaging?
Meta-Analysis
Does intravenous thrombolysis with alteplase or tenecteplase improve functional outcomes in patients with acute ischemic stroke 4.5-24 hours after onset when selected by imaging?
In imaging-selected patients with acute ischemic stroke, intravenous thrombolysis administered 4.5-24 hours after onset improves functional outcomes despite an increased risk of symptomatic intracranial hemorrhage.
BACKGROUND AND OBJECTIVES: Intravenous thrombolysis (IVT) is the standard treatment for acute ischemic stroke within 4.5 hours of onset. However, imaging-based selection may extend the treatment window. This systematic review and meta-analysis evaluated the efficacy and safety of IVT administered beyond 4.5 hours after stroke onset or last known well (LKW) in patients selected based on imaging findings. METHODS: A comprehensive search of PubMed, Scopus, and Cochrane Library was performed to identify randomized controlled trials comparing IVT with alteplase or tenecteplase (TNK) administered >4.5 hours after stroke onset/LKW vs standard care. Primary outcomes were 3-month excellent (modified Rankin Scale [mRS] 0-1) functional outcome and symptomatic intracranial hemorrhage (sICH). Secondary outcomes included good (mRS 0-2) functional outcome, recanalization, and 3-month mortality. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models. Subgroup analysis assessed differences between alteplase and TNK. RESULTS: = 0.11). DISCUSSION: Among patients selected based on imaging, 4.5-24 hours after stroke onset/LKW, IVT improves outcomes despite an increased risk of sICH. TNK showed similar efficacy to alteplase, with a possible lower risk of sICH; however, direct comparisons in future trials are needed.
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Rahmati et al. (2026) conducted a meta-analysis in acute ischemic stroke. Intravenous thrombolysis (alteplase or tenecteplase) vs. standard care was evaluated on 3-month excellent (modified Rankin Scale [mRS] 0-1) functional outcome and symptomatic intracranial hemorrhage (sICH). Intravenous thrombolysis administered 4.5-24 hours after stroke onset in imaging-selected patients improves outcomes despite an increased risk of symptomatic intracranial hemorrhage.
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