The clot-dissolving medication alteplase can improve stroke patients’ recovery by more than 50% when given up to 24 hours after the beginning of an ischaemic stroke, as per preliminary late-breaking science presented at the recent International Stroke Conference (ISC; 5–7 February, Los Angeles, USA).
These results from the prospective, multicentre, randomised HOPE study offer promise to stroke patients worldwide who may not be able to access clot-dissolving medications within the approved time window—which, in China, is within 4.5 hours—according to the trial’s principal investigator Min Lou (Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China).
“We believe these findings mean more people may return to normal or near-normal lives after a stroke, even if they receive treatment later than originally thought beneficial,” Lou commented. “This method of treatment could become the new standard, especially in hospitals that use CT [computed tomography] perfusion imaging. This technology helps healthcare professionals see how blood flows in different parts of the brain after an ischaemic stroke. This could extend treatment eligibility to millions more patients across the globe.”
In the USA, alteplase is approved to treat stroke within three hours of symptom onset and is recommended for use up to 4.5 hours for select patients, while some research has indicated it may also work well in certain patients 4.5–9 hours after stroke onset. American Heart Association/American Stroke Association guidelines from 2019 on the early management of patients with acute ischaemic stroke note that intravenous (IV) alteplase within 4.5 hours of stroke onset is the standard of care for most ischaemic stroke patients in the USA.
In the HOPE trial, researchers enrolled 372 stroke patients (average age, 72 years; 43% women) whose symptoms began between 4.5 hours and 24 hours earlier across 26 stroke centres in China. They used widely available CT perfusion imaging to confirm that these patients still had brain tissue that could be recovered with treatment. Participants were randomly split into two groups—one group received the clot-busting medication alteplase, while the other received standard stroke care involving antiplatelet therapy at the discretion of the investigator they were enrolled by and based on the 2018 Chinese guidelines for acute ischaemic stroke diagnosis and treatment. HOPE’s primary endpoint of functional recovery (modified Rankin scale [mRS] 0–1) was assessed at 90 days.
The study found that 40% of participants treated with alteplase had little-to-no disability after 90 days, compared to 26% of those who received standard care—equivalent to a 54% higher chance of functional recovery. In addition, less than 3% of participants in either group received rescue clot removal via mechanical thrombectomy as an additional treatment. Rates of death were the same (10.8%) for both groups, while the risk of brain bleeding was higher among those who received alteplase than among participants who did not (3.8% vs 0.5%)—a risk that the researchers believe is “manageable”.
“We also need to look more closely at how safe and effective other clot-dissolving medications like tenecteplase are when given after a stroke, especially beyond the usual timeframes,” Lou added. “It’s also important to learn if our findings apply to other groups of people, especially in areas with different stroke risks and healthcare resources.”
Study limitations include the fact that both participants and investigators knew which treatment was being given, which could have introduced bias, and results potentially not being generalisable to patients outside of China, according to the researchers.
