Low- versus Standard-dose Alteplase in Acute Lacunar Ischemic Stroke: The ENCHANTED Trial

Zien Zhou, Candice Delcourt, Chao Xia, Sohei Yoshimura, Cheryl Carcel, Takako Torii-Yoshimura, Shoujiang You, Alejandra Malavera, Xiaoying Chen, Maree L Hackett, Mark Woodward, John Chalmers, Jianrong Xu, Thompson G Robinson, Mark W Parsons, Andrew M Demchuk, Richard I Lindley, Grant Mair, Joanna M Wardlaw, Craig S Anderson

Research output: Contribution to journalArticlepeer-review


OBJECTIVE: To determine any differential efficacy and safety of low- versus standard-dose intravenous alteplase for lacunar versus non-lacunar acute ischemic stroke (AIS), we performed post-hoc analyzes from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) alteplase dose-arm.

METHODS: In a cohort of 3297 ENCHANTED participants, we identified those with lacunar or non-lacunar AIS with different levels of confidence (definite/probable/possible) according to pre-specified definitions based on clinical and adjudicated imaging findings. Logistic regression models were used to determine associations of lacunar AIS with 90-day outcomes (primary, modified Rankin scale [mRS] scores 2-6; secondary, other mRS scores, intracerebral hemorrhage [ICH], and early neurologic deterioration [END] or death) and treatment effects of low- versus standard-dose alteplase across lacunar and non-lacunar AIS with adjustment for baseline covariables.

RESULTS: Of 2588 participants with available imaging and clinical data, we classified cases as definite/probable lacunar (n=490) or non-lacunar AIS (n=2098) for primary analyses. Regardless of alteplase dose received, lacunar AIS participants had favorable functional (mRS 2-6, adjusted odds ratio [95% CI] 0.60 [0.47-0.77]) and other clinical or safety outcomes, compared to participants with non-lacunar AIS. Low-dose alteplase (versus standard) had no differential effect on functional outcomes (mRS 2-6, 1.04 [0.87-1.24]) but reduced the risk of symptomatic ICH in all included participants. There were no differential treatment effects of low- versus standard-dose alteplase on all outcomes across lacunar and non-lacunar AIS (all Pinteraction ≥0.07).

CONCLUSIONS: We found no evidence from the ENCHANTED trial that low-dose alteplase had any advantages over standard-dose for definite/probable lacunar AIS.

CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for patients with lacunar AIS, low-dose alteplase had no additional benefit or safety over standard-dose alteplase.

CLINICAL TRIAL REGISTRATION: ENCHANTED is registered at www.clinicaltrials.gov: NCT01422616.

Original languageEnglish
Early online date3 Feb 2021
Publication statusE-pub ahead of print - 3 Feb 2021

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