September 6, 2018

Background: Despite serious concerns about the role of alteplase in the management of acute ischemic stroke including, but not limited to, significant conflicts of interest, unbalanced baseline patient characteristics, systematic devaluation of contrary data, lack of reproduced benefit and low fragility index, it remains standard care for patients presenting with symptoms of acute ischemic stroke within 3 (or 4.5 depending on system) hours of onset of symptoms. Though the NINDS studies only showed benefit in a specific subgroup of patients, subsequent work has endeavored to expand the target group in a classic example of indication creep. Patients with minor CVA (NIHSS < 5 without disabling features or, essentially mRS 0-1) represent one such subgroup in which alteplase is often not employed due mainly in part to the perception of minimal benefit with continued potential for harm (i.e. anaphylaxis, intracranial hemorrhage). Alteplase supporters argue that minor stroke patients should still get the drug as it not only may reduce symptoms but can also prevent deterioration. The evidence for this viewpoint is both extremely limited and of poor methodologic quality.