Intravenous thrombolysis for ischemic stroke in extended time window selected with CT perfusion: a systematic review and meta-analysis
In brief
IV thrombolysis improves 3-month functional recovery up to 24 hours
In six randomized trials of 2,358 patients selected with CT perfusion, intravenous thrombolysis increased the chance of excellent and good functional outcomes at three months, with benefits seen as late as 24 hours after stroke onset. The treatment raised the risk of symptomatic brain bleeding but did not affect 90-day mortality, highlighting a trade-off that clinicians must weigh.
- Journal
- Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association (Q1)
- Published
- 31 July 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Marcello Naccarato, Edoardo Ricci, Emanuele Vincis, Magda Quagliotto, Michele Malesani, Gianpiero Farina, et al.
- PMID
- 42537729
- DOI
- 10.1016/j.jstrokecerebrovasdis.2026.108717
Why clinicians should know about it
- Picked for Radiology, Radiation Oncology, Nuclear Medicine, Medical Physics and Imaging (top studies of the week, 2 August 2026): Systematic review/meta‑analysis of IV thrombolysis in extended time window
- Picked for Rehabilitation (top studies of the week, 2 August 2026).
- Picked for Neurology (clinical) (top studies of the week, 2 August 2026).
Abstract
PURPOSE: Recent randomized controlled trials (RCTs) have provided new evidence regarding the efficacy and safety of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) presenting within the extended time window (ETW). We performed a systematic review and meta-analysis to evaluate the efficacy and safety of IVT, in patients treated within the ETW and selected with perfusion imaging criteria, predominantly computed tomography perfusion (CTP). METHODS: A systematic review and meta-analysis, registered in PROSPERO, was conducted including all available RCTs comparing IVT with best medical treatment (BMT) in patients with AIS within the ETW, selected using advanced perfusion imaging criteria. The predefined efficacy outcomes were excellent functional outcome and good functional outcome at 3 months. The safety endpoints included symptomatic intracranial hemorrhage (sICH) and all-cause mortality at 90 days. RESULTS: Six RCTs, including 1182 patients treated with IVT and 1176 patients receiving BMT, were included. IVT was associated with a higher likelihood of achieving excellent and good functional outcomes at 3 months. Exploratory subgroup analyses by treatment timing suggested consistent findings up to 24 hours. No significant difference in 90-day mortality was observed between groups, whereas IVT was associated with an increased risk of sICH. CONCLUSION: Treatment with IVT in the ETW (4.5-24 h) in patients selected using advanced perfusion imaging, predominantly CTP, may be associated with improved functional outcomes in patients with AIS. Although IVT was associated with an increased risk of sICH, no significant increase in 90-day mortality was observed. PROSPERO REGISTRATION: CRD420261304314.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.