medwireNews: Alteplase treatment given up to 24 hours after posterior circulation stroke to patients who did not have thrombectomy can increase their chances of functional independence compared with standard medical care, show findings from the EXPECTS trial.
At 90 days following stroke, Chinese patients who received intravenous alteplase at a dose of 0.9 mg/kg (up to a maximum of 90 mg) were 16% more likely to achieve functional independence than patients receiving standard mono or dual antiplatelet therapy in addition to statins. Functional independence was based on a score of 0–2 points out of a possible 6 points on the modified Rankin scale, where higher scores indicate greater disability.
This reflected a significant treatment effect in favor of alteplase after taking into account age, National Institutes of Health Stroke Scale (NIHSS) score at baseline, and time from stroke onset to treatment, the researchers report in The New England Journal of Medicine.
They also point out that “[t]he incidence of symptomatic intracranial hemorrhage within the first 36 hours was similar in the two groups.”
The team randomly assigned 117 patients to receive alteplase and 117 to receive standard medical therapy between 4.5 and 24.0 hours (median 9.4 hours) after the participants showed signs of posterior circulation stroke. This diagnosis was confirmed by diffusion-weighted magnetic resonance imaging or the lack of an alternative diagnosis on computed tomography scans.
The patients (65.4% men) had a median age of 64 years and most of them had mild stroke at the time of treatment, as indicated by a median NIHSS score of 3 points. The characteristics of the two groups were well balanced at baseline, although the investigators point out that a “slightly lower” proportion of patients in the alteplase group than the standard medical group had large artery atherosclerosis. None of the patients had received thrombectomy, although the study did allow for rescue thrombectomy, which was carried out in four patients in the alteplase treatment arm and seven in the standard treatment arm.
In all, 89.6% of patients treated with alteplase achieved functional independence at 90 days, significantly more than the 72.6% of patients receiving standard medical treatment.
The rates of intracranial hemorrhage within 36 hours of treatment were similar, at 1.7% and 0.9%, respectively, and there was no significant difference in the rates of death at 90 days, occurring in 5.2% versus 8.5%.
Min Lou (Zhejiang University, Hangzhou, China) and co-investigators acknowledge that the generalizability of their findings is limited regarding patients with moderate or severe strokes, and in populations other than the Han Chinese.
Nevertheless, they conclude that the results “support the use of alteplase in this extended time window” of 4.5 to 24.0 hours for patients who have mild posterior circulation strokes, “if endovascular thrombectomy is not available.”
medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2025 Springer Healthcare Ltd, part of the Springer Nature Group
