Perfusion-Selected Alteplase Extends Thrombolysis Window to 9 Hours

EXTEND provides the first randomized signal that imaging-selected patients can benefit from intravenous alteplase between 4.5 and 9 hours after stroke onset, reshaping how pharmacists evaluate late-window thrombolysis eligibility.

alteplasetissue plasminogen activatorthrombolyticsacute ischemic strokewake-up strokeperfusion imagingRAPID softwareendovascular thrombectomyrandomized controlled trialneurology Neurology / Neuropharmacology

Background Information

Alteplase shows promise for late-presenting stroke when guided by imaging.

Extending the thrombolysis window for acute ischemic stroke could improve outcomes for patients who wake with stroke symptoms or present late. The study found that 35.4% of patients treated with alteplase had minimal neurologic deficits at 90 days compared to 29.5% with placebo, despite increased bleeding risk. This trial supports the use of alteplase up to 9 hours after stroke onset in patients with salvageable tissue, though results were from an early termination and carry elevated bleeding risks. Alteplase may benefit some late-presenting stroke patients if imaging shows salvageable brain tissue.

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Authors: Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, Kleinig TJ, Wijeratne T, Curtze S, Dewey HM, Miteff F, Tsai CH, Lee JT, Phan TG, Mahant N, Sun MC, Krause M, Sturm J, Grimley R, Chen CH, Hu CJ, Wong AA, Field D, Sun Y, Barber PA, Sabet A, Jannes J, Jeng JS, Clissold B, Markus R, Lin CH, Lien LM, Bladin CF, Christensen S, Yassi N, Sharma G, Bivard A, Desmond PM, Yan B, Mitchell PJ, Thijs V, Carey L, Meretoja A, Davis SM, Donnan GA, EXTEND Investigators

Citation: Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. The New England journal of medicine. 2019;380(19):1795-1803. doi:10.1056/NEJMoa1813046

Article Links: PubMed · Journal / DOI

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Executive Summary

Study Design

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Secondary Outcomes & Safety Profile

Pharmacist Implications

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