Meta-analysis finds functional benefit from imaging-selected thrombolysis beyond 4.5 hours

A systematic review and meta-analysis published in Stroke evaluated intravenous thrombolysis in imaging-selected patients with acute ischemic stroke presenting beyond 4.5 hours or with wake-up/unknown-onset stroke. Investigators searched PubMed, Embase, and Cochrane Central through February 2026, identifying 14 randomized trials involving 4,192 participants comparing alteplase or tenecteplase with best medical therapy. The primary endpoint was excellent functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score of 0–1.

Thrombolysis increased the likelihood of an excellent functional outcome (risk ratio [RR], 1.22; 95% CI, 1.16–1.29) and functional independence, defined as mRS 0–2 (RR, 1.12; 95% CI, 1.06–1.18). Both agents contributed to these benefits. Symptomatic intracranial hemorrhage was more frequent with thrombolysis (RR, 2.58; 95% CI, 1.58–4.22). The difference in 90-day mortality was not statistically significant (RR, 1.15; 95% CI, 0.97–1.35).

The findings support imaging-based selection for delayed thrombolysis rather than selection solely by elapsed time, but apply to the imaging-selected populations studied. Functional benefits must be weighed against increased hemorrhage risk. The mortality confidence interval does not exclude clinically important harm. Only the abstract was available; absolute event rates, detailed imaging criteria, and trial-level risk-of-bias assessments were not provided.