Should Alteplase Be Used With Endovascular Thrombectomy for Ischemic Stroke?

Brain stroke : 3d illustration of the vessels of the brain and causes of stroke
Researchers sought to determine whether prespecified outcomes were different in endovascular thrombectomy with alteplase compared with EVT alone in patients hospitalized with acute ischemic stroke.

Despite elevating the risk for symptomatic intracranial hemorrhage (sICH), alteplase combined with endovascular thrombectomy (EVT) improved in-hospital survival rates and decreased overall disability in patients following acute ischemic stroke, according to findings published in JAMA Neurology.

Researchers conducted an observational, cohort study comparing patients with acute ischemic stroke 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 impacted discharge destination, patient ability to ambulate independently at discharge, modified Rankin score, mortality, and cerebral reperfusion based on the modified Thrombolysis in Cerebral Infarction grade.

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

Additionally, more patients treated with combined EVT and alteplase scored a grade of 2 or less on the modified Rankin scale at time of discharge than those treated without alteplase (28.5% vs 20.7%; aOR, 1.36; 95% CI, 1.28-1.45; P <.001), indicating decreased risk for major disability. Consequently, patients receiving alteplase were more likely to discharge to home (34.4% vs 27.5%) and ambulate independently at discharge (38.7% vs 30.4%).

Patients receiving alteplase demonstrated improved cerebral reperfusion, scoring 2b or greater on the modified Thrombolysis in Cerebral Infarction grade compared with patients who were not treated with alteplase (90.9% vs 88.0%; aOR, 1.39; 95% CI, 1.28-1.50; P <.001).

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

“Although alteplase treatment probably increases the risk [for] sICH after EVT in routine clinical practice, this does not translate to worsening in discharge disability or mortality,” the researchers stated. “Alteplase or other thrombolytics may still have an important role in patients undergoing EVT for large vessel occlusion, particularly in patients where a delay in accessing the angiography suite is anticipated…”

Study limitations included not reporting outcome assessment 90 days after patient discharge to predict disability, and not evaluating 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 (FDA).

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


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