T

Stroke workspace

Evidence
Clinician-reviewed CDS · Browser-local · No identifiers · Source-linkedRead more…

This tool is educational and informational. It does not replace clinical judgment. Verify trial evidence, guideline recommendations against the cited source before acting.

Not prospectively validated. No clinical tool replaces bedside assessment.

This tool qualifies as non-device clinical decision support under the January 2026 FDA CDS guidance (21st Century Cures Act §3060). It does not acquire or analyze patient data, it displays the basis for its recommendations, it enables independent clinician review, and it is intended for use by trained healthcare professionals.

This runs entirely in your browser; we store nothing. Even so, enter only clinical data (age, vitals, exam findings) -- not names, MRNs, or other identifiers.

Tarvinder Singh, MD -- Vascular Neurologist. March 2026.

Stroke Evidence Map

Stroke trials and guidelines organized by clinical question.

36
Established trials
4
Emerging signals
21
Guidelines
AHA/ASA 2026
Guideline source

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Clinical Question Index

QuestionTop ClassTrialsGuidelines
IVT StandardI/A35
IVT ExtendedIIa/B-R75
TNK Evidence--70
EVT EarlyI/A51
EVT LateI/A31
Large CoreI/A54
BasilarI/A32
MeVO/DistalIIa/B-R23
Adjuncts--10

IVT: Standard Window (0-4.5h)

Can I give IV thrombolysis within 4.5 hours?

Guidelines (5)

Class ILOE AAHA/ASA 2026, §4.6.1

IV alteplase/TNK within 3 hours

IV alteplase (0.9 mg/kg) or TNK (0.25 mg/kg single bolus) is recommended for eligible patients within 3 hours of symptom onset.

AHA/ASA 2026, §4.6.1

Class ILOE B-RAHA/ASA 2026, §4.6.2

IV alteplase/TNK 3–4.5 hours

IV alteplase/TNK is recommended for eligible patients 3–4.5 hours from onset, with additional exclusion criteria (age >80 per ECASS III).

AHA/ASA 2026, §4.6.2

Class ILOE AAHA/ASA 2026, §4.6.1 (AcT, ORIGINAL, ATTEST-2, TASTE, BRIDGE-TNK)

TNK is the recommended thrombolytic

Tenecteplase (0.25 mg/kg single IV bolus, max 25 mg) is the preferred thrombolytic. Pooled analysis of five RCTs (AcT, ORIGINAL, ATTEST-2, TASTE, BRIDGE-TNK) shows superiority over alteplase for excellent outcomes (OR 1.14 for mRS 0-1, 95% CI 1.03-1.25). Logistic advantages: single bolus vs. 1-hour infusion.

AHA/ASA 2026, §4.6.1 (AcT, ORIGINAL, ATTEST-2, TASTE, BRIDGE-TNK)

Class IIaLOE B-NRAHA/ASA 2026, §4.6.1, Table 4

IVT reasonable for mild but disabling deficits

IVT is reasonable for patients with mild but functionally disabling deficits (e.g., isolated aphasia, dominant-hand paresis in a surgeon, monocular blindness in a commercial driver). Per AHA/ASA 2026 Table 4: deficit severity is determined by functional impact, not NIHSS score alone. Do not withhold IVT solely because NIHSS is low.

AHA/ASA 2026, §4.6.1, Table 4

Class IIILOE B-RAHA/ASA 2026, §4.6.1, Table 4

IVT not recommended for non-disabling deficits

IVT is not recommended for patients with non-disabling deficits (e.g., isolated facial droop, mild non-dominant hand weakness, hemisensory loss). DAPT may be preferred. See Table 4 for deficit classification.

AHA/ASA 2026, §4.6.1, Table 4

Positive Trials (2)

NINDS

(1995)positiveLikely fit
NINDS 1995

Intervention: IV tPA (alteplase) 0.9 mg/kg

Landmark trial establishing IV tPA within 3 hours of stroke onset.

n = 624ARR 13%NNT 8sICH 6.4%

ECASS III

(2008)positiveLikely fit
ECASS III 2008

Intervention: IV tPA (alteplase) 0.9 mg/kg in 3–4.5h window

Extended IV tPA window to 4.5 hours with additional exclusion criteria.

n = 821ARR 7.2%NNT 14sICH 2.4%
Negative/Neutral Trials (1) — click to expand

IST-3

(2012)neutralLikely fit
IST-3 2012

Intervention: IV tPA (alteplase) 0.9 mg/kg within 6h

Large pragmatic trial of IV tPA up to 6 hours; included patients >80 years.

n = 3,035

IVT: Extended Window & Wake-up

Can I give IVT after 4.5 hours or for wake-up stroke?

Guidelines (5)

Class IIaLOE B-RAHA/ASA 2026, §4.6.3 (EXTEND, ECASS-4)

IV tPA/TNK 4.5–9h with perfusion mismatch

IV thrombolysis can be beneficial for selected patients 4.5–9h from known onset when perfusion imaging shows salvageable tissue. Wake-up strokes with unknown onset use ivt-perfusion-wakeup instead. EXTEND provides the strongest positive alteplase signal; ECASS-4 used broader MRI mismatch criteria and was neutral after early stopping, so the pathway should be framed as mismatch-selected benefit rather than guaranteed late-window efficacy.

AHA/ASA 2026, §4.6.3 (EXTEND, ECASS-4)

Class IIaLOE B-RAHA/ASA 2026, §4.6.3 (EXTEND)

IVT for wake-up stroke with CTP perfusion mismatch

IV thrombolysis can be beneficial for wake-up stroke patients with unknown onset when CTP perfusion imaging shows mismatch and ischemic core < 70 mL. This parallels the ivt-wakeup-mri (DWI-FLAIR) pathway but uses CT perfusion instead of MRI for onset estimation.

AHA/ASA 2026, §4.6.3 (EXTEND)

Class IIaLOE B-RAHA/ASA 2026, §4.6.3 (WAKE-UP)

IVT for wake-up stroke with DWI-FLAIR mismatch

IV alteplase can be beneficial for wake-up stroke patients with DWI-FLAIR mismatch on MRI, suggesting onset within 4.5h. (WAKE-UP trial: 53.3% vs 41.8% mRS 0-1)

AHA/ASA 2026, §4.6.3 (WAKE-UP)

Class IIbLOE B-RAHA/ASA 2026, §4.6.4 (OPTION)

IVT for non-LVO 4.5–24h with perfusion mismatch

TNK (0.25 mg/kg) may be reasonable for non-LVO patients 4.5–24h with perfusion mismatch. OPTION: 43.6% vs 34.2% mRS 0-1. Not all extended-window reperfusion trials show clinical benefit: CHABLIS-T II (n=224, LVO) achieved radiographic reperfusion at 4.5–24h but 90-day outcomes did not improve when 55% went to preplanned EVT — patient selection and EVT access determine the benefit.

AHA/ASA 2026, §4.6.4 (OPTION)

Class IIbLOE B-RAHA/ASA 2026, §4.6.4 (TRACE-III)

IVT for LVO 4.5–24h without EVT access, perfusion-selected

TNK (0.25 mg/kg) may be reasonable for LVO patients 4.5–24h when EVT is not available, selected by perfusion mismatch (core <70 mL, ratio ≥1.8). TRACE-III: 33.0% vs 24.2% mRS 0-1 (NNT 11), sICH 3.0% vs 0.8%. If EVT is available and feasible, prioritize EVT (Class I). This recommendation addresses community hospitals and settings where EVT access is delayed or unavailable.

AHA/ASA 2026, §4.6.4 (TRACE-III)

Positive Trials (4)

EXTEND

(2019)positiveLikely fit
EXTEND 2019

Intervention: IV tPA (alteplase) 4.5–9h with perfusion mismatch

IV tPA in extended window (4.5–9h or wake-up) selected by perfusion imaging mismatch.

n = 225ARR 5.9%NNT 17sICH 6.2%

WAKE-UP

(2018)positiveLikely fit
WAKE-UP 2018

Intervention: IV tPA (alteplase) guided by DWI-FLAIR mismatch in unknown-onset stroke

MRI-guided thrombolysis for stroke with unknown time of onset. DWI-FLAIR mismatch selects patients likely within 4.5h.

n = 503ARR 11.5%NNT 9sICH 2%

HOPE

(2025)positiveLikely fit
HOPE 2025

Intervention: IV alteplase 0.9 mg/kg in 4.5–24h with perfusion-defined salvageable tissue and no initial EVT plan

Alteplase in the 4.5–24h window for perfusion-selected patients who were not initially planned for thrombectomy. Positive — improved 90-day functional independence despite more sICH.

n = 372ARR 14%NNT 7sICH 3.8%

OPTION

(2026)positiveLikely fit
OPTION 2026

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg in 4.5–24h for non-LVO with perfusion mismatch

TNK in the extended window for non-LVO stroke with salvageable tissue on perfusion imaging. Positive — improved excellent 90-day outcome, with more sICH.

n = 570ARR 9.4%NNT 11sICH 2.8%
Negative/Neutral Trials (3) — click to expand

ECASS-4

(2019)neutralLikely fit
ECASS-4 2019

Intervention: IV tPA (alteplase) 0.9 mg/kg in 4.5–9h with MRI mismatch selection

MRI-selected alteplase trial in the extended window. Neutral overall result after early termination, but directionally aligned with later mismatch-selected thrombolysis evidence.

n = 119sICH 1.6%

TIMELESS

(2024)negativeLikely fit
TIMELESS 2024

No benefit of adding TNK to EVT in the late window (4.5–24h) — applies when EVT is rapidly available

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg in 4.5–24h with perfusion mismatch + EVT

TNK in extended window (4.5–24h) with perfusion mismatch in LVO patients also receiving EVT. Negative — no additional benefit when EVT is available.

n = 458sICH 4%

CHABLIS-T II

(2025)neutralLikely fit
CHABLIS-T II 2025

Extended-window TNK achieved reperfusion but NO clinical benefit at 90 days when EVT was preplanned (55% received EVT)

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg vs best medical treatment in 4.5–24h with CTP mismatch selection (anterior LVO)

Phase IIb extended-window TNK trial in CTP-selected anterior LVO patients. Primary imaging endpoint met (reperfusion 33.3% vs 10.8%, RR 3.0), but no difference in 90-day functional outcomes. 55% of patients went to preplanned EVT.

n = 224sICH 9%

IVT: TNK vs Alteplase

Which thrombolytic agent should I use?

Positive Trials (5)

TRACE-III

(2024)positiveLikely fit
TRACE-III 2024

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg in 4.5–24h for LVO patients without EVT access, selected by perfusion mismatch

TNK in extended window (4.5–24h) for LVO patients without EVT access, selected by perfusion mismatch.

n = 516ARR 8.8%NNT 11sICH 3%

ORIGINAL

(2024)positiveLikely fit
ORIGINAL 2024

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg vs alteplase within 4.5h

Largest TNK non-inferiority trial (n=1465). TNK non-inferior to alteplase for mRS 0-1 at 90 days in Chinese stroke patients within 4.5h.

n = 1,465sICH 1.2%

TASTE

(2024)positiveLikely fit
TASTE 2024

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg vs alteplase, CTP-selected, non-EVT candidates

Non-inferiority trial of TNK vs alteplase in CTP-selected patients within 4.5h who were not EVT candidates. Non-inferior per-protocol; ITT did not meet NI margin.

n = 680sICH 3%

BRIDGE-TNK

(2025)positiveLikely fit
BRIDGE-TNK 2025

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg before EVT vs EVT alone for LVO

Bridge therapy trial: TNK before EVT vs EVT alone in LVO patients within 4.5h. TNK+EVT superior for functional independence (52.9% vs 44.1% mRS 0-2). Definitively answers "should I give IVT before EVT?" — Yes.

n = 550ARR 8.8%NNT 12sICH 8.5%

AcT

(2022)positiveLikely fit
AcT 2022

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg vs alteplase

Non-inferiority trial of TNK vs alteplase. TNK was non-inferior, simpler to administer (single bolus).

n = 1,600sICH 3.4%
Negative/Neutral Trials (2) — click to expand

ATTEST-2

(2024)neutralLikely fit
ATTEST-2 2024

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg vs alteplase within 4.5h

Largest UK TNK non-inferiority trial (n=1777). TNK non-inferior to alteplase for mRS distribution at 90 days, but superiority was explicitly tested and NOT demonstrated (OR 1.07, p=0.43).

n = 1,777sICH 2.3%

TEMPO-2

(2024)negativeLikely fit
TEMPO-2 2024

Stopped for futility with 5x mortality signal (5% vs 1%, adjusted HR 3.8, p=0.0085) in minor stroke with occlusion — do not lyse NIHSS 0–5

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg vs standard of care for minor stroke with proven occlusion

Superiority trial of TNK vs non-thrombolytic standard of care in minor ischemic stroke (NIHSS 0–5) with proven intracranial occlusion or perfusion abnormality, within 12h. Stopped early for futility at 886 of 1274 planned patients (70%) — no benefit and a significant mortality signal.

n = 886sICH 2%
Tier 3 Emerging

Post-IVT Adjunctive Tirofiban Signal

ASSET-IT

ASSET-IT (N=832) found that IV tirofiban within 60 minutes after thrombolysis improved 90-day outcomes in noncardioembolic stroke (mRS 0-1: 65.9% vs 54.9%, P=0.001), but with an asymmetric sICH signal: 1.7% vs 0% (7 events vs 0).

Single Chinese multicenter trial of non-EVT-eligible patients (median NIHSS 6, ASPECTS 10). Not incorporated into AHA/ASA 2026 guidelines. The sICH asymmetry — seven events versus zero — requires replication before adjunctive post-IVT tirofiban enters standard practice.

EVT: Early Window (0-6h)

Standard anterior LVO thrombectomy within 6 hours?

Guidelines (1)

Class ILOE AAHA/ASA 2026, §4.7.2

EVT within 6 hours for anterior LVO

Mechanical thrombectomy is recommended for patients with anterior LVO (ICA, M1) within 6 hours of onset, NIHSS ≥6, ASPECTS ≥3, pre-mRS 0-1. Do NOT skip IVT to facilitate EVT; do NOT delay EVT to observe IVT response. For NIHSS <6 with LVO and functionally disabling deficit, see COR IIb mild-disabling pathway.

AHA/ASA 2026, §4.7.2

Positive Trials (5)

MR CLEAN

(2015)positiveLikely fit
MR CLEAN 2015

Intervention: Intra-arterial treatment (EVT) within 6h

First positive EVT trial. Proved benefit of endovascular treatment for anterior LVO.

n = 500ARR 13.5%NNT 8sICH 7.7%

ESCAPE

(2015)positiveLikely fit
ESCAPE 2015

Intervention: EVT within 12h with favorable imaging

EVT with emphasis on fast workflow and favorable collaterals on multiphase CTA.

n = 316ARR 23.7%NNT 4sICH 3.6%

EXTEND-IA

(2015)positiveLikely fit
EXTEND-IA 2015

Intervention: EVT after IV tPA with CTP-selected patients

EVT in patients with target perfusion mismatch on CTP, after IV tPA.

n = 70ARR 31%NNT 3sICH 0%

SWIFT PRIME

(2015)positiveLikely fit
SWIFT PRIME 2015

Intervention: Solitaire stent retriever + IV tPA within 6h

EVT with Solitaire device in anterior LVO patients who received IV tPA.

n = 196ARR 25%NNT 4sICH 0%

REVASCAT

(2015)positiveLikely fit
REVASCAT 2015

Intervention: Solitaire stent retriever within 8h

EVT in anterior LVO within 8 hours. Confirmed benefit across pre-specified subgroups.

n = 206ARR 15.5%NNT 6sICH 1.9%

EVT: Late Window (6-24h)

EVT beyond 6 hours with mismatch selection?

Guidelines (1)

Class ILOE AAHA/ASA 2026, §4.7.2 (DAWN, DEFUSE 3, MR CLEAN-LATE)

EVT 6–24h with perfusion/clinical mismatch

EVT is recommended for eligible patients 6–24h from LKW with anterior LVO (ICA, M1), NIHSS ≥6, ASPECTS ≥6, pre-mRS 0-1 who meet DAWN, DEFUSE-3, or MR CLEAN-LATE mismatch criteria. Phase 3 (2026-04-13): objective pathway gating -- a bare `perfusionMismatch=true` boolean does NOT open Class I-selected EVT; one of the three computed pathways must qualify.

AHA/ASA 2026, §4.7.2 (DAWN, DEFUSE 3, MR CLEAN-LATE)

Positive Trials (3)

DAWN

(2018)positiveLikely fit
DAWN 2018

Intervention: EVT 6–24h with clinical-core mismatch (Trevo device)

Extended EVT window to 24h using clinical-core mismatch on CTP/DWI. Paradigm-shifting trial.

n = 206ARR 36%NNT 3sICH 6%

DEFUSE 3

(2018)positiveLikely fit
DEFUSE 3 2018

Intervention: EVT 6–16h with perfusion mismatch

EVT in 6–16h window selected by automated perfusion mismatch (RAPID software).

n = 182ARR 28%NNT 4sICH 7%

MR CLEAN-LATE

(2023)positiveLikely fit
MR CLEAN-LATE 2023

Intervention: EVT 6–24h with collateral-based CTA selection

EVT in the late window (6–24h) using collateral flow on CTA rather than perfusion-software selection. Netherlands multicenter phase 3 trial (n=502 mITT, 535 randomized). Specifically excluded DAWN/DEFUSE-3-eligible patients.

n = 502ARR 9%NNT 11sICH 7%

EVT: Large Core

Should I treat large ischemic core (ASPECTS 3-5)?

Guidelines (4)

Class ILOE AAHA/ASA 2026, §4.7.2 (SELECT2, ANGEL-ASPECT, RESCUE-Japan LIMIT, TENSION)

EVT for large ischemic core (ASPECTS 3-5)

EVT is recommended for patients with large ischemic core (ASPECTS 3-5 on CTP/DWI, or core ≥50 mL) within 6-24h of onset with anterior LVO, NIHSS ≥6, pre-mRS 0-1, age <80, and no major mass effect. (SELECT2, ANGEL-ASPECT, RESCUE-Japan LIMIT: 0–24h; TENSION: 0–12h). Caution: SELECT2 found ≥26 mL severe hypodensity on NCCT (≤26 HU) was associated with no benefit; TESLA (NCCT-only selection) was neutral — advanced imaging (CTP or DWI) preferred for patient selection when feasible.

AHA/ASA 2026, §4.7.2 (SELECT2, ANGEL-ASPECT, RESCUE-Japan LIMIT, TENSION)

Class IIaLOE B-NRAHA/ASA 2026, §4.7.2

EVT for very large core (ASPECTS 0-2)

EVT can be beneficial for patients with anterior ICA/M1 occlusion, ASPECTS 0-2, within 6h, pre-mRS 0-1, age <80, no major edema. Evidence is limited; underrepresented: age >80, vessel tortuosity, seizures at onset, intracranial stenosis, life expectancy <6 months.

AHA/ASA 2026, §4.7.2

Class IIaLOE B-NRAHA/ASA 2026, §4.7.2

EVT for patients with pre-mRS 2

EVT can be beneficial for patients with anterior LVO (ICA, M1), pre-stroke mRS of 2, within 6h, NIHSS ≥6, ASPECTS ≥6. Treatment should be individualized based on patient goals and baseline function.

AHA/ASA 2026, §4.7.2

Class IIbLOE B-NRAHA/ASA 2026, §4.7.2

EVT for patients with pre-mRS 3-4

EVT may be reasonable for patients with anterior LVO (ICA, M1), pre-stroke mRS 3-4, within 6h, NIHSS ≥6, ASPECTS ≥6. Limited evidence; individualized decision based on goals of care.

AHA/ASA 2026, §4.7.2

Positive Trials (4)

SELECT2

(2023)positiveLikely fit
SELECT2 2023

Intervention: EVT for large ischemic core (ASPECTS 3-5 or core 50+ mL)

International RCT (31 centers, 5 countries) showing EVT benefit in large core infarcts previously excluded from trials. Required CTP or DWI for core quantification. Stopped early at 352/560 (63%) after RESCUE-Japan LIMIT results.

n = 352ARR 13.3%NNT 8sICH 0.6%

ANGEL-ASPECT

(2023)positiveLikely fit
ANGEL-ASPECT 2023

Intervention: EVT for large core (ASPECTS 3-5) within 24h

Chinese RCT confirming EVT benefit in large core strokes (ASPECTS 3-5).

n = 456ARR 13.7%NNT 7sICH 6.1%

RESCUE-Japan LIMIT

(2022)positiveLikely fit
RESCUE-Japan LIMIT 2022

Intervention: EVT for large core (ASPECTS 3-5) within 6h (or 24h with mismatch)

Japanese trial confirming EVT benefit in large core strokes.

n = 203ARR 18.3%NNT 6

TENSION

(2024)positiveLikely fit
TENSION 2024

Intervention: EVT for large core on NCCT or DWI (ASPECTS 3-5) within 11h

EVT for large core selected by NCCT ASPECTS alone (no CTP required). European trial. Stopped early for efficacy.

n = 253ARR 18%NNT 6sICH 6%
Negative/Neutral Trials (1) — click to expand

TESLA

(2024)negativeLikely fit
TESLA 2024

Bayesian negative — NCCT-only large-core EVT showed sICH 4.0% vs 1.3% and PH2 9.5% vs 3.4% without meeting efficacy threshold (posterior probability 0.96 < 0.975)

Intervention: EVT for large core on NCCT (ASPECTS 2-5) within 24h — no CTP/DWI required

Bayesian negative — EVT for large ischemic core selected by NCCT ASPECTS alone (no perfusion imaging). The only negative large-core EVT trial.

n = 300sICH 4%

EVT: Basilar Artery

Posterior circulation occlusion treatment?

Guidelines (2)

Class ILOE AAHA/ASA 2026, §4.7.3 (ATTENTION, BAOCHE)

EVT for basilar artery occlusion

EVT is recommended for basilar occlusion within 24h, NIHSS ≥10, PC-ASPECTS ≥6, pre-mRS 0-1. Upgraded from IIa to Class I based on ATTENTION (46% vs 23% mRS 0-3) and BAOCHE (46% vs 24% mRS 0-3).

AHA/ASA 2026, §4.7.3 (ATTENTION, BAOCHE)

Class IIbLOE B-RAHA/ASA 2026, §4.7.3 (BAOCHE subgroup)

EVT for basilar occlusion with lower NIHSS (6–9)

EVT may be considered for basilar occlusion with NIHSS 6–9, PC-ASPECTS ≥6, pre-mRS 0-1, within 24h. Based on BAOCHE subgroup analysis showing benefit in the NIHSS ≥6 population, though primary endpoint powered for NIHSS ≥10.

AHA/ASA 2026, §4.7.3 (BAOCHE subgroup)

Positive Trials (2)

ATTENTION

(2022)positiveLikely fit
ATTENTION 2022

Intervention: EVT for acute basilar artery occlusion within 12h

First positive basilar EVT trial. Significant benefit of thrombectomy for acute basilar occlusion within 12 hours.

n = 340ARR 23%NNT 4sICH 5.3%

BAOCHE

(2022)positiveLikely fit
BAOCHE 2022

Intervention: EVT for basilar artery occlusion 6–24h

EVT for basilar occlusion in extended window (6–24h). Significant benefit with PC-ASPECTS ≥ 6.

n = 217ARR 22%NNT 5sICH 5.9%
Negative/Neutral Trials (1) — click to expand

BASICS

(2021)neutralLikely fit
BASICS 2021

Intervention: EVT for acute basilar artery occlusion within 6h

Neutral result: EVT did not significantly improve outcomes over medical care for basilar artery occlusion within 6 hours.

n = 300sICH 4.5%
Tier 3 Emerging

Posterior-Circulation TNK Signal

TRACE-5

TRACE-5 reported better 90-day functional outcome with tenecteplase for basilar occlusion within 24 hours: 38% vs 29% achieved mRS 0-1 or returned to baseline (adjusted relative rate 1.50), with similar sICH (2% vs 3%) and mortality (29% vs 31%).

This is one post-guideline phase 3 signal. AHA/ASA 2026 has not yet incorporated TRACE-5, so the recommendation tier above does not change on the basis of this trial alone.

Publication Watch

ATTENTION-LATE Basilar TNK Bridging — Publication Watch

ATTENTION-LATE tested IV tenecteplase bridging before EVT for basilar artery occlusion in a multicenter phase 3 trial (N=330). ISC 2026 late-breaking results reported no benefit of bridging TNK over EVT alone.

Conference abstract only — not yet peer-reviewed or indexed on PubMed. Outcome numbers are withheld until the primary results paper publishes. This is a negative signal for TNK bridging in posterior circulation, complementing the positive TRACE-5 signal for TNK monotherapy in basilar occlusion.

EVT: MeVO & Distal Occlusions

EVT for medium vessel or distal occlusions?

Guidelines (3)

Class IIaLOE B-RAHA/ASA 2026, §4.7.2

EVT for dominant M2 occlusion

EVT can be beneficial for dominant M2 occlusions within 6h causing significant deficit (NIHSS ≥6), ASPECTS ≥6, pre-mRS 0-1. Upgraded from IIb (2019) to IIa based on ASTER2 and subgroup data.

AHA/ASA 2026, §4.7.2

Class IIbLOE B-NRAHA/ASA 2026, §4.7.2

EVT for mild but disabling LVO stroke (NIHSS <6)

EVT may be reasonable for patients with anterior LVO and NIHSS <6 when the deficit is functionally disabling (e.g., isolated aphasia, dominant-hand weakness in a surgeon). Individualize based on deficit impact, patient goals, and procedural risk.

AHA/ASA 2026, §4.7.2

Class IIILOE AAHA/ASA 2026, §4.7.2-4.7.3

EVT not beneficial for distal vessel occlusions

EVT is not recommended for distal vessel occlusions (M2 nondominant/codominant, M3, ACA, PCA). Randomized MeVO trials did not show routine benefit and showed safety concerns.

AHA/ASA 2026, §4.7.2-4.7.3

Negative/Neutral Trials (2) — click to expand

ESCAPE-MeVO

(2025)negativeLikely fit
ESCAPE-MeVO 2025

EVT did not improve outcomes for MeVO (M2/M3/A2-3/P2-3) — sICH doubled (5.4% vs 2.2%) with significant excess mortality (13.3% vs 8.4%, aHR 1.82)

Intervention: EVT vs best medical therapy for medium vessel occlusions (M2, M3, A2, A3, P2, P3)

EVT for medium-vessel occlusions did not improve 90-day disability compared with usual care and showed a statistically significant mortality signal (aHR 1.82, 95% CI 1.06-3.12). The 2026 AHA/ASA guideline rates distal MCA-M2 EVT as COR 3: No Benefit.

n = 530sICH 5.4%

DISTAL

(2025)negativeLikely fit
DISTAL 2025

EVT for medium/distal occlusions showed harm signal — sICH 5.9% vs 2.6% without functional benefit

Intervention: EVT plus best medical therapy vs best medical therapy alone for medium or distal vessel occlusions

DISTAL reinforced the negative MeVO signal: EVT did not improve 90-day disability for medium/distal vessel occlusions and showed more symptomatic hemorrhage.

n = 543sICH 5.9%

Neuroprotection & Post-Reperfusion Adjuncts

Post-reperfusion optimization and neuroprotection?

Negative/Neutral Trials (1) — click to expand

ESCAPE-NA1

(2020)negativeLikely fit
ESCAPE-NA1 2020

Intervention: Nerinetide 2.6 mg/kg IV single dose during EVT vs placebo

Neuroprotection with nerinetide during EVT for anterior LVO. Negative overall; no benefit of nerinetide added to EVT.

n = 1,105sICH 3.5%
Publication Watch

LAIS Phase III Neuroprotection — Publication Watch

LAIS tested IV loberamisal (a PSD-95/nNOS dissociator and GABA-A potentiator) started within 48 hours of acute ischemic stroke onset in a multicenter, double-blind, placebo-controlled phase III trial across 32 Chinese centers (N=998). ISC 2026 late-breaking results reported a positive primary endpoint. Phase II results (N=240) were not statistically significant (PMID 41218852).

Blocked until a primary results paper with verified PubMed metadata exists. The neuroprotection field has a long history of positive phase II/III trials that fail replication across populations — NXY-059 (SAINT II), NA-1/nerinetide (ESCAPE-NA1), and dozens of others. Single-country, single-trial status warrants particular caution. Conference abstracts are not peer-reviewed.

Emerging Evidence

Tier 3 -- informational

Early-stage trials and evolving signals. Per ADR-002 the evidence-tier hierarchy is guidelines > pivotal RCTs > emerging, and these entries should inform research and signal-tracking rather than alter bedside recommendations until they clear the higher tiers.

TRACE-5

(2026)positiveTier 3Likely fit
TRACE-5 2026

Intervention: IV Tenecteplase (TNK) 0.25 mg/kg within 24h for basilar artery occlusion

First positive randomized basilar TNK trial. Important posterior-circulation signal, but not yet incorporated into AHA/ASA 2026 recommendations.

n = 452sICH 2%

CHOICE

(2022)positiveTier 3Likely fit
CHOICE 2022

Intervention: Adjunct intra-arterial alteplase 0.225 mg/kg (max 22.5 mg) over 15-30 minutes after successful thrombectomy

Phase 2b post-thrombectomy rescue trial. Intra-arterial alteplase improved excellent 90-day outcome after successful reperfusion, but the study stopped early during the COVID-19 era and needs replication before changing standard care.

n = 121ARR 18.6%NNT 6sICH 0%

ATTENTION-IA

(2025)neutralTier 3Likely fit
ATTENTION-IA 2025

Intervention: Intra-arterial tenecteplase 0.0625 mg/kg (max 6.25 mg) after successful posterior-circulation EVT

Posterior-circulation post-recanalization rescue trial. Intra-arterial tenecteplase after successful EVT did not significantly improve 90-day disability and showed more symptomatic ICH.

n = 208sICH 8.3%

ASSET-IT

(2025)positiveTier 3Likely fit
ASSET-IT 2025

Intervention: IV Tirofiban within 60 minutes after IV thrombolysis for noncardioembolic acute ischemic stroke

First positive randomized trial of adjunctive antiplatelet therapy after IVT. Strong efficacy signal but asymmetric sICH (1.7% vs 0%), requiring replication before entering standard practice.

n = 832sICH 1.7%

Chronology

Year-ordered index of every acute-stroke trial in the catalog. Grouped by decade; expand a decade to see individual trials with PMID link.

2020s(27 trials)
2010s(11 trials)
2000s(1 trial)
1990s(1 trial)