A Comprehensive Systematic Review of The Relationship Between Onset-to-Needle Time and Recanalization Success in Ischemic Stroke
Keywords:
Onset-to-needle time, Door-to-needle time, Ischemic stroke, Recanalization, Thrombolysis, Thrombectomy, Functional outcome, Time-to-treatmentAbstract
Introduction: The effectiveness of reperfusion therapies in acute ischemic stroke is highly time-dependent, with earlier treatment generally associated with better outcomes. However, the precise relationship between onset-to-needle time (ONT) and recanalization success, and how this relationship varies across treatment modalities and patient subgroups, requires systematic synthesis of the extensive and sometimes heterogeneous evidence.
Methods: A systematic review was conducted, screening sources based on strict criteria including adult acute ischemic stroke patients receiving intravenous thrombolysis (IVT), clear reporting of ONT, and assessment of recanalization via validated imaging. Data were extracted from 80 eligible studies, encompassing randomized controlled trials, cohort studies, and meta-analyses, with sample sizes ranging from 24 to 12,529 patients. Extraction focused on time metrics, treatment modalities, recanalization rates, functional outcomes, safety data, and statistical relationships.
Results: A strong inverse relationship exists between ONT and recanalization success. Ultra-early treatment within the "golden hour" (≤60 minutes) achieved a 44% recanalization rate compared to 12% when treated after one hour (Bernatowicz et al., 2016). A clear dose-response effect was evident, with the odds of favorable outcome declining from 2.8 for treatment within 90 minutes to 1.2 for 271-360 minutes (Hacke et al., 2004). For patients with large vessel occlusion (LVO) receiving bridging IVT before thrombectomy, the benefit becomes non-significant beyond approximately 2 hours 20 minutes (Kaesmacher et al., 2024). Each 15-minute delay in door-to-needle time was associated with 20.3 fewer excellent outcomes per 1000 patients (Goyal et al., 2019). Safety outcomes, including symptomatic intracranial hemorrhage rates, did not show a significant increase with earlier treatment.
Discussion: The synthesized evidence underscores "time is brain" as a fundamental principle. Heterogeneity in effect sizes is explained by differences in patient populations (e.g., LVO vs. non-LVO), treatment contexts (IVT alone vs. bridging therapy), and study methodologies. The benefit of IVT extends to extended time windows (4.5-24 hours) when guided by advanced imaging selection (Campbell et al., 2020; Rahmati et al., 2025). Workflow innovations, such as mobile stroke units and protocols favoring tenecteplase, significantly reduce critical time intervals and improve outcomes (Czap et al., 2021; Henderson et al., 2024).
Conclusion: Earlier onset-to-needle time is consistently and powerfully associated with higher rates of successful recanalization and improved functional independence in acute ischemic stroke. This relationship is quantifiable and should drive clinical protocols and public health initiatives aimed at minimizing all pre- and in-hospital delays. Treatment decisions in extended windows must be individualized using advanced neuroimaging.
References
A. Ciccone, L. Valvassori, M. Nichelatti, A. Sgoifo, M. Ponzio, R. Sterzi, and E. Boccardi. “Endovascular Treatment for Acute Ischemic Stroke.” New England Journal of Medicine, 2013.
A. Czap, A. Alexandrov, M. Nour, Noopur Singh, Mengxi Wang, Jose-Miguel Yamal, Stephanie A. Parker, R. Bowry, and J. Grotta. “Abstract 1122‐000126: Mobile Stroke Unit Process Metrics in Large Vessel Occlusion Stroke Patients: BEST‐MSU Substudy.” Stroke: Vascular and Interventional Neurology, 2021.
B. Campbell, Henry Ma, M. Parsons, L. Churilov, N. Yassi, T. Kleinig, C. Hsu, et al. “Abstract 100: Reperfusion Improves Clinical Outcome Across the 4.5-9h and Wake-Up Stroke Time Continuum in EXTEND and EPITHET.” Stroke, 2020.
B. Campbell, Henry Ma, M. Parsons, L. Churilov, N. Yassi, T. Kleinig, Chung Y. Hsu, et al. “Association of Reperfusion After Thrombolysis With Clinical Outcome Across the 4.5- to 9-Hours and Wake-Up Stroke Time Window: A Meta-Analysis of the EXTEND and EPITHET Randomized Clinical Trials.” JAMA Neurology, 2020.
B. Campbell, P. Mitchell, B. Yan, M. Parsons, S. Christensen, L. Churilov, R. Dowling, et al. “A Multicenter, Randomized, Controlled Study to Investigate Extending the Time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial Therapy (EXTEND-IA).” International Journal of Stroke, 2014.
B. Campbell, P. Mitchell, T. Kleinig, H. Dewey, L. Churilov, N. Yassi, B. Yan, et al. “Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection.” New England Journal of Medicine, 2015.
B. Eskin. “In Ischemic Stroke, IV Alteplase Within 3 h of Onset Improves Functional Outcome Vs. Control.” Annals of Internal Medicine, 2022.
Blake Henderson, Rebecca Emborski, Alessandra Diioia, David Stone, and Kyle Stupca. “Improved Door-to-Needle Time After Implementation of Tenecteplase as the Preferred Thrombolytic for Acute Ischemic Stroke at a Large Community Teaching Hospital Emergency Department.” Hospital Pharmacy, 2024.
Chih‐Hao Chen, Sung-Chun Tang, Yu‐Wei Chen, Chih‐Hung Chen, L. Tsai, S. Sung, Huey-Juan Lin, et al. “Effectiveness of Standard-Dose Vs. Low-Dose Alteplase for Acute Ischemic Stroke Within 3–4.5 h.” Frontiers in Neurology, 2022.
D. Buck, Lisa Shaw, C. Price, and G. Ford. “Reperfusion Therapies for Wake-Up Stroke: Systematic Review.” Stroke, 2014.
Diego Gutierrez, K. Ignacio, Aleksander Tkach, H. M. Manosalva Alzate, Fouzi Bala, MacKenzie Horn, H. Khosravani, et al. “Abstract WMP54: Outcomes of Acute Ischemic Stroke Patients in Primary Stroke Centers Versus Comprehensive Stroke Centers: A Pre-Specified Analysis of the Alteplase Compared to Tenecteplase Trial.” Stroke, 2025.
E. Bluhmki, Á. Chamorro, A. Dávalos, T. Machnig, Christophe Sauce, N. Wahlgren, J. Wardlaw, and W. Hacke. “Stroke Treatment with Alteplase Given 3·0–4·5 h After Onset of Acute Ischaemic Stroke (ECASS III): Additional Outcomes and Subgroup Analysis of a Randomised Controlled Trial.” Lancet Neurology, 2009.
E. Nourollahzadeh, O. Kass-Hout, M. Mokin, R. Aliotta, K. Snyder, A. Siddiqui, E. Levy, and T. Kass-Hout. “Abstract 3798: Correlation Between Recanalization Rate and Good Clinical Outcome in Acute Ischemic Stroke, A Meta-Analysis.” Stroke, 2012.
E. Nourollahzadeh, O. Kass-Hout, M. Mokin, R. Aliotta, K. Synder, A. Siddiqui, E. Levy, and T. Kass-Hout. “P-046 Correlation Between Recanalization Rate and Good Clinical Outcome in Acute Ischemic Stroke, a Meta-Analysis.” Journal of NeuroInterventional Surgery, 2012.
G. D. Graham. “Meta-Analysis: Alteplase Improves Functional Outcomes When Given Within 4.5 Hours of Stroke Onset.” Annals of Internal Medicine, 2010.
Hailili Reziya, Kadeer Sayifujiamali, Haichao Han, Xi-Ming Wang, Tusun Nuerbiya, Damaola Nuerdong, Qiang Sang, and Yanan Wu. “Real-Time Feedback on Mobile Application Use for Emergency Management Affects the Door-to-Needle Time and Functional Outcomes in Acute Ischemic Stroke.” Journal of Stroke & Cerebrovascular Diseases, 2023.
Henry Ma, B. Campbell, M. Parsons, C. Levi, A. Meretoja, L. Churilov, S. Christensen, et al. “Abstract 59: Extending the Time for Thombolysis in Emergency Neurological Deficits (EXTEND) - High Prevalence of Intracranial Vessel Occlusion in Wake-up-Stroke Patients,” 2016.
Henry Ma, Henry Ma, M. Parsons, S. Christensen, B. Campbell, L. Churilov, A. Connelly, et al. “A Multicentre, Randomized, Double-Blinded, Placebo-Controlled Phase III Study to Investigate Extending the Time for Thrombolysis in Emergency Neurological Deficits (EXTEND).” International Journal of Stroke, 2012.
Huaguang Zheng, Yi Yang, Huisheng Chen, Chuan-ling Li, Yangkun Chen, F. Shi, Li Yang, et al. “Thrombolysis with Alteplase 3–4.5 Hours After Acute Ischaemic Stroke: The First Multicentre, Phase III Trial in China.” Stroke and Vascular Neurology, 2020.
I. Maier, D. Behme, Marlena Schnieder, I. Tsogkas, K. Schregel, A. Kleinknecht, K. Wasser, et al. “Bridging-Therapy with Intravenous Recombinant Tissue Plasminogen Activator Improves Functional Outcome in Patients with Endovascular Treatment in Acute Stroke.” Journal of Neurological Sciences, 2017.
Ims Study Investigators. “Combined Intravenous and Intra-Arterial Recanalization for Acute Ischemic Stroke: The Interventional Management of Stroke Study.” Stroke, 2004.
Ivy A. Sebastian, and Michael D Hill. “In Ischemic Stroke, Adding IV Thrombolysis ≤2 h After Symptom Onset to Thrombectomy Was Associated with Benefit.” Annals of Internal Medicine, 2024.
J. C. Ozaeta, Samuel Dadzie, Christopher S. Chinnatambi, Alex Kumi, Sammudeen Ibrahim, and Christopher March. “Abstract DP3: Thrombolysis for Ischemic Stroke After 4.5 Hours Without Thrombectomy: A Meta-Analysis of Randomized Controlled Trials.” Stroke, 2025.
J. Emberson, Kennedy R. Lees, Patrick D Lyden, L. Blackwell, G. Albers, E. Bluhmki, T. Brott, et al. “Effect of Treatment Delay, Age, and Stroke Severity on the Effects of Intravenous Thrombolysis with Alteplase for Acute Ischaemic Stroke: A Meta-Analysis of Individual Patient Data from Randomised Trials.” The Lancet, 2014.
J. Kaesmacher, F. Cavalcante, M. Kappelhof, K. Treurniet, L. Rinkel, Jianmin Liu, B. Yan, et al. “Abstract 22: Time to Treatment and the Effect of Intravenous Thrombolysis Before Thrombectomy: An Individual Participant Data Meta-Analysis.” Stroke, 2024.
J. Kaesmacher, F. Cavalcante, M. Kappelhof, K. Treurniet, L. Rinkel, Jianmin Liu, B. Yan, et al. “Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis.” Journal of the American Medical Association (JAMA), 2024.
J. Kirmani, D. Korya, S. Mehta, J. Brar, Azka Shaikh, Rushil Kalola, M. Samaan, A. Arango, Spozhmy Panezai, and M. Moussavi. “Abstract WP2: Symptom Onset to Groin Puncture Determines Stroke Outcome: A Meta-Analysis of Recent Acute Cerebrovascular Thrombectomy-After-Infarction Trials (MR ACTION).” Stroke, 2016.
J. Ospel, Nishita Singh, M. Almekhlafi, B. Menon, A. Butt, A. Poppe, A. Jadhav, et al. “Early Recanalization With Alteplase in Stroke Because of Large Vessel Occlusion in the ESCAPE Trial.” Stroke, 2020.
J. R. Marler, B. Tilley, M. Lu, T. Brott, P. Lyden, James C. Grotta, Joseph P. Broderick, et al. “Early Stroke Treatment Associated with Better Outcome: The Ninds Rt-Pa Stroke Study.” Neurology, 2000.
J. Rha, and J. Saver. “The Impact of Recanalization on Ischemic Stroke Outcome: A Meta-Analysis.” Stroke, 2007.
J. Saver, M. Goyal, A. Bonafe, H. Diener, E. Levy, V. Pereira, G. Albers, et al. “Stent-Retriever Thrombectomy After Intravenous t-PA Vs. T-PA Alone in Stroke.” New England Journal of Medicine, 2015.
Jie Yang, Xia Wang, Jianping Yu, Jing Hang, P. Lavados, T. Robinson, H. Arima, R. Lindley, C. Anderson, and J. Chalmers. “Positive Impact of the Participation in the ENCHANTED Trial in Reducing Door-to-Needle Time.” Scientific Reports, 2017.
Junya Aoki, K. Kimura, K. Shibazaki, Koichiro Nagai, Naoki Saji, Jyunichi Uemura, Takahiro Sato, and Takuya Ebata. “Abstract W P56: Negative FLAIR-Based Intravenous Thrombolysis in Acute Stroke Patients With Unknown Onset Time.” Stroke, 2014.
Junya Aoki, Kentaro Suzuki, Y. Sakamoto, Y. Matsumaru, M. Takeuchi, M. Morimoto, R. Kanazawa, et al. “Ultra-Early Rt-PA Administration Should Improve Patient Outcome on Mechanical Thrombectomy: Post Hoc Analysis of SKIP.” Journal of Neurological Sciences, 2023.
K. Kimura, Y. Iguchi, K. Shibazaki, Junya Aoki, Masao Watanabe, Kazuto Kobayashi, and Y. Sakamoto. “Recanalization Within One Hour After Intravenous Tissue Plasminogen Activator Is Associated with Favorable Outcome in Acute Stroke Patients.” European Neurology, 2010.
K. Kimura, Y. Iguchi, K. Shibazaki, Kazuto Kobayashi, J. Uemura, Junya Aoki, Shinji Yamashita, Y. Terasawa, and N. Matsumoto. “Recanalization Between 1 and 24 Hours After t-PA Therapy Is a Strong Predictor of Cerebral Hemorrhage in Acute Ischemic Stroke Patients.” Journal of Neurological Sciences, 2008.
Kristi G. Bache, M. R. Hov, K. Larsen, V. Solyga, and C. Lund. “Prehospital Advanced Diagnostics and Treatment of Acute Stroke: Protocol for a Controlled Intervention Study.” JMIR Research Protocols, 2018.
L. Mai, and W. Oczkowski. “Tenecteplase Before Thrombectomy for Ischemic Stroke Improved Reperfusion Compared with Alteplase.” Annals of Internal Medicine, 2018.
L. Rinkel, K. Treurniet, M. Kappelhof, N. LeCouffe, A. Bruggeman, D. Nieboer, W. van Zwam, et al. “Influence of Time Metrics on the Treatment Effect of Intravenous Alteplase Prior to Endovascular Treatment in MR CLEAN-NO IV.” Journal of NeuroInterventional Surgery, 2022.
M. Alberts. “Faculty Opinions Recommendation of Stroke Treatment with Alteplase Given 3.0-4.5 h After Onset of Acute Ischaemic Stroke (ECASS III): Additional Outcomes and Subgroup Analysis of a Randomised Controlled Trial.” 2010.
M. Goyal, A. Demchuk, B. Menon, M. Eesa, J. Rempel, J. Thornton, D. Roy, et al. “Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke.” New England Journal of Medicine, 2015.
M. Goyal, A. Jadhav, A. Bonafe, H. Deiner, V. Pereira, E. Levy, B. Baxter, et al. “Abstract TP25: Analysis of Workflow and Time to Treatment in the Swift Prime Randomized Controlled Trial,” 2016.
M. Goyal, B. Menon, Liqiong Fan, A. Demchuk, S. Yeatts, M. Hill, T. Tomsick, et al. “Abstract 143: Evaluation of Interval Times from Onset to Recanalization in Patients Undergoing Endovascular Therapy in the IMS III Trial,” 2014.
M. Goyal, M. Almekhlafi, D. Dippel, B. Campbell, K. Muir, A. Demchuk, S. Bracard, et al. “Rapid Alteplase Administration Improves Functional Outcomes in Patients With Stroke Due to Large Vessel Occlusions: Meta-Analysis of the Noninterventional Arm From the HERMES Collaboration.” Stroke, 2019.
M. Goyal, M. Almekhlafi, Liqiong Fan, B. Menon, A. Demchuk, S. Yeatts, M. Hill, et al. “Evaluation of Interval Times From Onset to Reperfusion in Patients Undergoing Endovascular Therapy in the Interventional Management of Stroke III Trial.” Circulation, 2014.
M. Hill. “In Imaging-Selected Ischemic Stroke with Unknown Onset, Alteplase Increases Favorable Outcomes and Death at 90 d.” Annals of Internal Medicine, 2021.
M. Siarkowski, Katie Lin, Shari S Li, Abdulaziz S Al Sultan, H. Ganshorn, N. Kamal, M. Hill, and E. Lang. “Meta-Analysis of Interventions to Reduce Door to Needle Times in Acute Ischaemic Stroke Patients.” BMJ Open Quality, 2020.
M. Tariq, Asha P. Jacob, Mengxi Wang, Jose-Miguel Yamal, M. Nour, A. Alexandrov, A. Alexandrov, et al. “Abstract Number ‐ 277: Mobile Stroke Unit Direct to Angiosuite Process Metrics and Clinical Outcomes.” Stroke: Vascular and Interventional Neurology, 2023.
MD Diego Gutiérrez, MD Katrina Ignacio, MD Aleksander Tkach, MD Herbert Manosalva, MD DPhil Aravind Ganesh, MD MacKenzie Horn, MD Houman Khosravani, et al. “Intravenous Thrombolysis at Primary Stroke Centers Versus Comprehensive Stroke Centers: Analysis from the AcT Trial.” medRxiv, 2025.
Mostafa Hashim, Hany Aref, A. El-bassiouny, A. H. El-Sudany, E. M. Abushady, and Amr S. Zaki. “Safety and Efficacy of Combined Thrombolysis and Thrombectomy in the Extended Time Window of Acute Ischemic Stroke.” The Quarterly Journal of Medicine, 2024.
N. Quang Anh, V. Dang Luu, L. Hoang Khoe, T. Anh Tuan, L. Hoang Kien, N. Thu Trang, N. Tat Thien, et al. “Effect of Mechanical Thrombectomy with Vs. Without Intravenous Thrombolysis in Acute Ischemic Stroke.” Clinica Terapeutica, 2022.
N. Shamalov, D. Khasanova, S. Marchenko, M. Soldatov, T. P. Alekseeva, O. Androfagina, L. N. Antipova, et al. “Thrombolytic Therapy with Revelisa in Ischemic Stroke: Results of the PRIMA International Multicenter Observational Study.” Neurology, Neuropsychiatry, Psychosomatics, 2025.
N. Singh, M. Almekhlafi, F. Bala, A. Ademola, S. Coutts, Y. Deschaintre, H. Khosravani, et al. “Effect of Time to Thrombolysis on Clinical Outcomes in Patients With Acute Ischemic Stroke Treated With Tenecteplase Compared to Alteplase: Analysis From the AcT Randomized Controlled Trial.” medRxiv, 2023.
N. Wahlgren, N. Ahmed, A. Dávalos, W. Hacke, M. Millán, K. Muir, R. Roine, D. Toni, and K. Lees. “Thrombolysis with Alteplase 3–4·5 h After Acute Ischaemic Stroke (SITS-ISTR): An Observational Study.” The Lancet, 2008.
O. Kass-Hout, T. Kass-Hout, M. Mokin, A. Siddiqui, E. Levy, and K. Synder. “P-045 The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.” Journal of NeuroInterventional Surgery, 2012.
O. Kass-Hout, T. Kass-Hout, M. Mokin, D. Orion, S. Jahshan, P. Yashar, E. Levy, A. Siddiqui, and K. Snyder. “Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.” 2012.
Q. Bai, Zhenguo Zhao, H. Sui, Xiuhai Xie, Juan Chen, and Juan Yang. “Fast Magnetic Resonance Imaging-Based Thrombolysis in Patients with Wake-up Ischemic Strokes,” 2014.
Qiang Huang, Haiqing Song, Xun‐ming Ji, W. Cheng, Juan Feng, Jian Wu, and Qing‐feng Ma. “Generalization of the Right Acute Stroke Prevention Strategies in Reducing in-Hospital Delays.” PLoS ONE, 2016.
R. Advani, H. Naess, and M. Kurz. “The Golden Hour of Acute Ischemic Stroke.” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2017.
R. Yamamoto, Yuko Amano, Naoya Kamimura, K. Amari, Fumiaki Tanaka, M. Takeuchi, M. Morimoto, et al. “Abstract WP12: Intravenous Thrombolysis in Unknown Time of Symptom Onset: Real World Data from the K-NET Registry.” Stroke, 2025.
Rodica Bernatowicz, M. Donohue, M. Hussain, S. John, D. Wisco, and K. Uchino. “Arterial Recanalization in the Golden Hour of IV tPA Administration for Ischemic Stroke (S47.003).” Neurology, 2016.
Rodica Bernatowicz, M. Donohue, M. Hussain, Seby John, D. Wisco, and Ken Uchino. “Arterial Recanalization in the Golden Hour of IV tPA Administration for Ischemic Stroke (I6.007).” Neurology, 2016.
S. Suzuki, B. Nguyen, I. Yuki, J. Xu, and M. Fisher. “E-069 Preventability of Stroke Due to Large Vessel Occlusion Treated with Mechanical Thrombectomy.” Electronic Poster Abstracts, 2020.
Shuangzhe Wu, Liyuan Wang, Zhixin Cao, M. Hao, Na Wu, Kejia Shen, Yizhe Tang, et al. “Tenecteplase for Ischemic Stroke Due to Large Vessel Occlusion at 4.5 to 24 Hours: A Meta‐Analysis of Randomized Controlled Trials.” Brain and Behavior, 2025.
Shuya Li, Runqi Wangqin, Yuesong Pan, A. Jin, Hao Li, L. Schwamm, M. Fisher, et al. “Outcomes Associated to the Time to Treatment with Intravenous Tenecteplase for Acute Ischaemic Stroke: Subgroup Analysis of the TRACE-2 Randomised Controlled Clinical Trial.” Stroke and Vascular Neurology, 2024.
Soheil Rahmati, Mohammadreza Alinejadfard, Yasaman Zarinfar, Amir Moradi, Amir Ghabousian, Ali Moradi, Kimia Najafi, et al. “Abstract 4347593: An Updated Meta-Analysis of Extended Thrombolytic Treatment Windows for Acute Ischemic Stroke.” Circulation, 2025.
T. Kass-Hout, M. Mokin, O. Kass-Hout, M. Darkhabani, D. Orion, S. Jahshan, P. Yashar, E. Levy, A. Siddiqui, and K. Snyder. “P-005 Is Bridging with Intravenous Thrombolysis of Any Benefit in Endovascular Therapy of Acute Ischemic Stroke?” Journal of NeuroInterventional Surgery, 2011.
T. Meinel, J. Kaesmacher, Lukas Buetikofer, D. Strbian, O. Eker, C. Cognard, P. Mordasini, et al. “Time to Treatment with Bridging Intravenous Alteplase Before Endovascular Treatment:subanalysis of the Randomized Controlled SWIFT-DIRECT Trial.” Journal of NeuroInterventional Surgery, 2022.
T. Ogata, S. Christensen, Y. Nagakane, Henry Ma, B. Campbell, L. Churilov, M. Lansberg, et al. “The Effects of Alteplase 3 to 6 Hours After Stroke in the EPITHET–DEFUSE Combined Dataset: Post Hoc Case–Control Study.” Stroke, 2013.
T. Tomsick, J. Broderick, J. Carrozella, P. Khatri, Michael D. Hill, Y. Palesch, and J. Khoury. “Revascularization Results in the Interventional Management of Stroke II Trial.” American Journal of Neuroradiology, 2008.
W. Guerrero, A. Alexandrov, P. Lyden, Y. Alderazi, Jessica D. Lee, S. Martin-Schild, Loren F Shen, et al. “Abstract WP71: Recanalization Leads To Early Clinical Improvement In Patients Treated With Argatroban And Intravenous TPA A Subanalysis Of The Argatroban Tpa Stroke Study,” 2013.
W. Hacke, G. Donnan, C. Fieschi, M. Kaste, R. Kummer, J. Broderick, T. Brott, et al. “Association of Outcome with Early Stroke Treatment: Pooled Analysis of ATLANTIS, ECASS, and NINDS Rt-PA Stroke Trials.” The Lancet, 2004.
W. Hacke, M. Kaste, E. Bluhmki, M. Brozman, A. Dávalos, D. Guidetti, V. Larrue, et al. “Thrombolysis with Alteplase 3 to 4.5 Hours After Acute Ischemic Stroke.” New England Journal of Medicine, 2008.
Xiyang Ji, Bo Song, Haoxu Zhu, Zhao Jiang, Feng Hua, Sa Wang, Jianbo Zhou, et al. “A Study on Endovascular Treatment Alone and Bridging Treatment for Acute Ischemic Stroke.” European Journal of Medical Research, 2023.
Y. Zhou, Lei Zhang, J. Ospel, M. Goyal, R. McDonough, P. Xing, Zifu Li, et al. “Association of Intravenous Alteplase, Early Reperfusion, and Clinical Outcome in Patients With Large Vessel Occlusion Stroke: Post Hoc Analysis of the Randomized DIRECT-MT Trial.” Stroke, 2022.
Yu Yao, Xiaoqin Zhang, Chang Liu, Lingling Cai, Yisha Ying, Yuefei Wu, and Jianhong Yang. “Real-World Data of Tenecteplase Versus Alteplase in the Treatment of Acute Ischemic Stroke: A Single-Center Analysis.” medRxiv, 2024.
Yuhui Chen, Lei Xu, P. Qi, Jun Lu, Juan Chen, and T. Gong. “Efficacy of Different Vascular Recanalization Methods for Acute Ischemic Stroke,” 2019.
Zhen Li, Lili Zheng, Junke Zheng, and Meiping Zhao. “Impact of Academic Center for Evidence-Based Practice Star Model on Door-to-Needle Times in Patients with Acute Ischemic Stroke.” Pakistan Journal of Medical Sciences, 2025.
Zhongyu Luo, Ying Zhou, Yaode He, Shenqiang Yan, Zhicai Chen, Xuting Zhang, Yi Chen, et al. “Treatment with Intravenous Alteplase in Ischaemic Stroke Patients with Onset Time Between 4.5 and 24 Hours (HOPE): Protocol for a Randomised, Controlled, Multicentre Study.” Stroke and Vascular Neurology, 2023.
Zhou Ying Zhang Ruiting Zhang Sheng Lou Min Zhang Meixia. “Maximal Infarct Volume to Benefit from Intravenous Thrombolysis and Its Relation with Onset to Treatment Time,” 2017.
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