Alteplase Before Thrombectomy Loses Value After 170 Minutes

Mechanical thrombectomy is the established standard of care for patients presenting with acute ischemic stroke due to large-vessel occlusion in the anterior circulation [1, 2]. While clinical guidelines generally support bridging therapy, which involves the administration of a clot-dissolving agent like intravenous alteplase prior to the endovascular procedure, the added value of this approach for patients admitted directly to thrombectomy-capable centers remains a point of contention [3, 4, 5]. A meta-analysis of 2,143 patients found no significant difference in functional independence, defined as a modified Rankin Scale score of 0 to 2 at 90 days, between direct mechanical thrombectomy and bridging therapy, reporting a pooled odds ratio of 0.96 (95% CI, 0.79 to 1.17; p = 0.39) [6, 7]. Conversely, a larger systematic review of 36,123 patients suggested that bridging therapy was associated with a 21 percent higher likelihood of favorable functional outcomes (RR 1.21, 95% CI 1.13 to 1.29) and lower mortality (RR 0.75, 95% CI 0.68 to 0.82) [5]. These discrepancies often stem from variations in treatment delays and the status of the penumbra, the region of ischemic but still salvageable brain tissue surrounding the irreversible infarct core. A new analysis of international trial data now clarifies how the interval from symptom onset to treatment dictates the clinical and economic viability of bridging therapy.