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Prompt treatment with alteplase essential for patients with severe ischaemic stroke

Assessing the risks in patients grouped together by stroke severity and knowing the outcomes. 
stroke

Thrombolysis with alteplase significantly improves the odds of an excellent outcome when delivered within 4.5 hours of the onset of ischaemic stroke but it also increases the risk of intracerebral haemorrhage, causing death or functional impairment.

This reanalysis of previous studies aimed to determine relative risks of haemorrhage in different types of patients. The study aimed to assess the absolute risks and benefits in patients grouped by stroke severity, age and treatment delay.

Findings were that the absolute benefits of alteplase decreased with treatment delay, and the absolute harm from intracranial haemorrhage increased with stroke severity. When delivered in 4.5 hours, the proportion of patients with good outcome exceeded those dying from intracranial haemorrhage.

However, because the risk of haemorrhage is highest in patients with the most severe stroke, prompt treatment of

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Thrombolysis with alteplase significantly improves the odds of an excellent outcome when delivered within 4.5 hours of the onset of ischaemic stroke but it also increases the risk of intracerebral haemorrhage, causing death or functional impairment.

increasing stroke risks
Prompt treatment with alteplase after acute ischaemic stroke is essential. Picture: iStock

This reanalysis of previous studies aimed to determine relative risks of haemorrhage in different types of patients. The study aimed to assess the absolute risks and benefits in patients grouped by stroke severity, age and treatment delay.

Findings were that the absolute benefits of alteplase decreased with treatment delay, and the absolute harm from intracranial haemorrhage increased with stroke severity. When delivered in 4.5 hours, the proportion of patients with good outcome exceeded those dying from intracranial haemorrhage.

However, because the risk of haemorrhage is highest in patients with the most severe stroke, prompt treatment of these patients is particularly important. Age was not found to be a significant factor when assessing risk.

Greater outcome

Researchers believe that knowledge of these absolute risk estimates will be useful when discussing the benefits and dangers of alteplase with patients and families.

The study concludes that although alteplase increases the risk of haemorrhagic stroke, when it is given within 4.5 hours of acute ischaemic stroke the odds of having an excellent outcome are greater than the risk of dying from an intracerebral haemorrhage.

The greatest risk of haemorrhage is for those with the most severe strokes so it is essential that treatment is given promptly.


Whiteley W, Emberson J, Lees K et al (2016) Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis. The Lancet. Neurology. 15, 9, 925-933. 

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