Late Alteplase Improves Outcomes in Posterior Circulation Stroke

Study at a glance:

• Journal: New England Journal of Medicine, 2024

• Population: 234 Chinese adults with mild posterior circulation ischemic stroke

• Method: Randomized trial comparing intravenous alteplase 4.5–24 hours after symptom onset versus standard medical treatment

• Key Finding: Alteplase increased functional independence at 90 days with low risk of symptomatic intracranial hemorrhage

Summary:
This Chinese multicenter trial evaluated whether intravenous alteplase administered 4.5 to 24 hours after symptom onset improves outcomes in patients with mild posterior circulation ischemic stroke who were not scheduled for thrombectomy. A total of 234 patients were randomized to receive alteplase (0.9 mg/kg) or standard medical care. Functional independence at 90 days (modified Rankin Scale score 0–2) was achieved in 89.6% of patients in the alteplase group versus 72.6% in the standard-treatment group (adjusted risk ratio, 1.16; 95% CI, 1.03–1.30; P = 0.01). Symptomatic intracranial hemorrhage occurred in 1.7% versus 0.9%, and 90-day mortality was 5.2% versus 8.5% in the alteplase and standard care groups, respectively.

Takeaway:
For patients with mainly mild posterior circulation stroke who are ineligible for thrombectomy, alteplase administered up to 24 hours after onset increases functional independence with a low risk of serious complications.

Source: Yan S, Zhou Y, Lansberg MG, et al. Alteplase for Posterior Circulation Ischemic Stroke at 4.5 to 24 Hours. N Engl J Med. 2025 Apr 3;392(13):1288-1296. doi: 10.1056/NEJMoa2413344. Available at : https://www.nejm.org/doi/10.1056/NEJMoa2413344