Should Alteplase Be Used With Endovascular Thrombectomy for Ischemic Stroke?

Despite the increased risk of symptomatic intracranial hemorrhage (sICH), alteplase in combination with endovascular thrombectomy (EVT) improved in-hospital survival rates and reduced overall disability in patients after acute ischemic stroke, according to findings published in JAMA Neurology.

Researchers conducted an observational cohort study comparing acute ischemic stroke patients treated with EVT and alteplase with those who had EVT without alteplase from February 1, 2019 to June 30, 2020.

In addition to sICH, the researchers evaluated how alteplase therapy affected discharge destination, the patient’s ability to walk independently at discharge, altered Rankin score, mortality, and cerebral reperfusion based on the altered thrombolysis grade of cerebral infarction.

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Of the 15,832 patients who underwent EVT within 6 hours of an acute ischemic stroke, 10,548 (66.6%) received alteplase, while the remaining 5284 (33.4%) did not. Patients treated with both EVT and alteplase showed improved in-hospital survival rates compared to patients receiving EVT alone (11.1% vs 13.9%; adjusted odds ratio [aOR], 0.83; 95% CI, 0.77-0.89; p <.001).

In addition, more patients treated with combined EVT and alteplase scored a grade of 2 or less on the modified Rankin scale at discharge than those treated without alteplase (28.5% vs. 20.7%; aOR 1 .36, 95% CI 1.28-1.45; p <.001), indicating a reduced risk of severe disability. Consequently, patients receiving alteplase were more likely to go home (34.4% vs. 27.5%) and walk independently at discharge (38.7% vs. 30.4%).

Patients receiving alteplase showed improved cerebral reperfusion and scored 2b or higher on the modified thrombolysis in stroke grade compared to patients not treated with alteplase (90.9% vs. 88.0%; aOR 1.39; 95% CI 1.28-1.50; p <.001).

In contrast to the positive outcomes, alteplase therapy increased the risk of sICH in this patient population (6.5% vs. 5.3%; OR 1.28; 95% CI 1.16-1.42; p <.001).

“Alteplase treatment likely increases risk” [for] sICH after EVT in daily clinical practice, this does not translate into a worsening of discharge limitations or mortality,” the researchers said. “Alteplase or other thrombolytics may still play an important role in patients undergoing EVT for large vessel occlusion, especially in patients who are expected to experience a delay in accessing the angiography suite…”

Study limitations include failure to report outcome assessment 90 days after patient discharge to predict disability, and failure to evaluate the use of tenecteplase instead of alteplase due to the current lack of approval of tenecteplase for patients with acute ischemic stroke by the Food and Drug Administration. and Drug Administration (FDA).

Disclosures: Some study authors stated that they have ties to biotech, pharmaceutical and/or device companies. See the original reference for a full list of author disclosures.


Smith EE, Zerna C, Solomon N, et al. Outcomes after endovascular thrombectomy with or without alteplase in everyday clinical practice. JAMA Neurol. Published online June 13, 2022. doi:10.1001/jamaneurol.2022.1413

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