Neurology in critical care · Thrombolysis beyond the clock
Alteplase for Acute Ischemic Stroke at 4.5 to 24 Hours
| Design | Phase 3 multicentre randomised clinical trial |
|---|---|
| Treatment | Intravenous alteplase 4.5 to 24 hours after onset, with imaging selection |
| Control | Standard medical treatment |
| Population | 372 patients, median age 72, 43% women |
| Follow-up | 90 days |
| Primary endpoint | Excellent functional outcome at 90 days |
| Result | The primary outcome occurred in 75 of 186 (40%) in the alteplase group and 49 of 186 (26%) in the control group. |
| Secondary endpoints | Modified Rankin shift, symptomatic intracranial haemorrhage, mortality |
In patients with acute ischemic stroke with salvageable brain tissue identified by perfusion imaging who did not initially receive thrombectomy, intravenous alteplase administered 4.5 to 24 hours after onset provided functional benefit, despite an increase in symptomatic intracranial hemorrhage.
The trial authors, in the published abstract
Takes the logic of WAKE-UP and EXTEND to its conclusion: with the right imaging, some patients benefit a full day after onset. A 14 percentage point absolute difference is substantial; the constraint is access to the imaging that identifies who those patients are.
Zhou Y, He Y, Campbell BCV, et al. Alteplase for Acute Ischemic Stroke at 4.5 to 24 Hours: The HOPE Randomized Clinical Trial. JAMA 2025 Sep 2;334(9):788-797.