EXPECTS More Alteplase

Posterior circulation stroke 4.5 - 24 hours.

Ah, some of us recall the early days of alteplase, when stroke treatment was provided up to three hours and strict eligibility criteria applied. Violations of that protocol were sure to result in patient harm, as seen in the various ECASS, or as described in Cleveland.

Obviously, those days are long gone, and every few months we find a new article describing the benefits of thrombolytic therapy in a new clinical scenario, in a further extended time window – this time, “mild” posterior circulation stroke in the 4.5-24h time window.

The main/minor quibble I have with their results reporting is the main manuscript sticks to the Intention-To-Treat population, when over 10% cross over or undergo some other treatment. Ideally, you’d report Per-Protocol outcomes in a better place than buried in the Supplementary Appendix – particularly when it’s an open-label trial and the patients and clinicians involved are aware of group assignment, directly affecting the integrity of the randomization. The results still favor alteplase, but not by quite as much:

There are also some lovely inclusion and exclusion criteria, including:

• Any condition that, in the judgment of the investigator, could impose hazards if study therapy is initiated or affect patient participation in the study

• The judgment is left to the discretion of the investigator

But, anyone who has followed the evolution of stroke treatment over the past couple decades will find it readily predictable these results will likely percolate into routine practice sooner, rather than later.