Beneficial is still NOWHERE CLOSE TO 100% RECOVERY!
But by using the tyranny of low expectations they will declare success, but survivors call anything less than 100% recovery A FUCKING FAILURE!
Thrombolysis Window May Extend to 24 Hours for Non-LVO Strokes
Caveat in Chinese trial was the increased symptomatic intracranial hemorrhage risk
In people with acute non-large vessel occlusion (LVO) strokes in the 4.5- to 24-hour window -- selected for having salvageable brain tissue -- an excellent functional outcome (modified Rankin Scale scores 0 or 1) at 90 days was more likely with tenecteplase than usual care (43.6% vs 34.2%, adjusted risk ratio [RR] 1.32, 95% CI 1.08-1.61), according to Ran Mo, MD, of Xuanwu Hospital Capital Medical
The tradeoff was safety: symptomatic intracranial hemorrhage within 36 hours occurred in some cases after treatment (2.8% vs 0%, P=0.004), though there was ultimately no excess mortality within 90 days (5.0% vs 3.2%, RR 1.57, 95% CI 0.69-3.57), Mo reported at the International Stroke Conference. The OPTION manuscript was simultaneously published in JAMA.
"The OPTION trial, which was conducted in China, convincingly demonstrated that treatment with IV tenecteplase benefits selected patients there who have tissue that is at risk but not completely infarcted if they can be treated in the window of time between 4.5 and 24 hours after onset of stroke, or after the time they were last known to be normal," commented Dana Leifer, MD, a neurologist at Weill Cornell Medicine and NewYork-Presbyterian Hospital in New York City.
Mo noted that the majority of acute ischemic strokes (AIS) are non-LVO, and these are not helped by the endovascular therapy (EVT) established for patients with LVO of the internal carotid artery, proximal middle cerebral artery, vertebral artery, or basilar artery within 24 hours.
In contrast, IV thrombolysis -- using either tenecteplase or alteplase -- is well established for patients with non-LVO strokes within 4.5 hours. There have been notable efforts to expand these criteria, however.
The TRACE-III trial suggested late administration of tenecteplase can improve clinical outcomes, albeit in people with LVO strokes. That was followed by HOPE, which made the case for alteplase at 4.5 to 24 hours for people with stroke clots in large and medium vessels not planned for EVT.
Recognizing these studies, the latest American stroke guideline update went as far as to give IV thrombolysis a recommendation in the 9-hour window for AIS patients with salvageable ischemic penumbra (class IIa). While extended IV thrombolysis out to 24 hours may be considered for LVO strokes not planned for EVT (class IIb), there was no verdict on such an extended window for selected non-LVO strokes.
Careful patient selection is emphasized for the safety of going this route.
Mo's group had required that OPTION participants have target mismatch profile on CT perfusion imaging defined as an ischemic core volume <50mL, a mismatch ratio ≥1.2, and a mismatch volume ≥10mL.
"Of note, symptomatic intracranial hemorrhage developed in two of the 21 patients with CT hypodensities larger than the core defined by CT perfusion scan with post hoc mismatch inconsistency," the authors wrote. "Therefore, careful evaluation of noncontrast CT hypodensity is advisable when considering late-window thrombolytic therapy."
OPTION was an open-label trial conducted at 48 Chinese centers. From June 2023 to August 2025, investigators enrolled 566 late-presenting people with non-LVO stroke and evidence of potentially salvageable tissue on imaging. Excluded were individuals already treated with a thrombolytic in the prior 72 hours, those with contraindications to thrombolysis, and those planned for EVT, among others.
Participants were ultimately randomized to IV tenecteplase (0.25 mg/kg, maximum dose 25 mg) or standard medical treatment.
The study cohort had a median age of 68 years and was 34.6% women. Occlusions were most commonly in the M2 segment of the middle cerebral artery (MCA; over 30%).
Mo and colleagues acknowledged that occlusions of the dominant M2 segment of the MCA had been suggested to benefit from EVT in prior trials.
"This trial was performed in a Chinese population, and findings may not fully generalize to populations of other races or ethnicities," they also cautioned.
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