The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial

Peter Sandercock, Joanna M Wardlaw, Richard I Lindley, Martin Dennis, Geoff Cohen, Gordon Murray, Karen Innes, Graham Venables, Anna Czlonkowska, Adam Kobayashi, Stefano Ricci, Veronica Murray, Eivind Berge, Karsten Bruins Slot, Graeme J Hankey, Manuel Correia, Andre Peeters, Karl Matz, Phillippe Lyrer, Gord GubitzStephen J Phillips, Antonio Arauz, IST-3 Collaborative Group, Phyo Kyaw Myint

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BACKGROUND: Thrombolysis is of net benefit in patients with acute ischaemic stroke, who are younger than 80 years of age and are treated within 4·5 h of onset. The third International Stroke Trial (IST-3) sought to determine whether a wider range of patients might benefit up to 6 h from stroke onset.

METHODS: In this international, multicentre, randomised, open-treatment trial, patients were allocated to 0·9 mg/kg intravenous recombinant tissue plasminogen activator (rt-PA) or to control. The primary analysis was of the proportion of patients alive and independent, as defined by an Oxford Handicap Score (OHS) of 0-2 at 6 months. The study is registered, ISRCTN25765518.

FINDINGS: 3035 patients were enrolled by 156 hospitals in 12 countries. All of these patients were included in the analyses (1515 in the rt-PA group vs 1520 in the control group), of whom 1617 (53%) were older than 80 years of age. At 6 months, 554 (37%) patients in the rt-PA group versus 534 (35%) in the control group were alive and independent (OHS 0-2; adjusted odds ratio [OR] 1·13, 95% CI 0·95-1·35, p=0·181; a non-significant absolute increase of 14/1000, 95% CI -20 to 48). An ordinal analysis showed a significant shift in OHS scores; common OR 1·27 (95% CI 1·10-1·47, p=0·001). Fatal or non-fatal symptomatic intracranial haemorrhage within 7 days occurred in 104 (7%) patients in the rt-PA group versus 16 (1%) in the control group (adjusted OR 6·94, 95% CI 4·07-11·8; absolute excess 58/1000, 95% CI 44-72). More deaths occurred within 7 days in the rt-PA group (163 [11%]) than in the control group (107 [7%], adjusted OR 1·60, 95% CI 1·22-2·08, p=0·001; absolute increase 37/1000, 95% CI 17-57), but between 7 days and 6 months there were fewer deaths in the rt-PA group than in the control group, so that by 6 months, similar numbers, in total, had died (408 [27%] in the rt-PA group vs 407 [27%] in the control group).

INTERPRETATION: For the types of patient recruited in IST-3, despite the early hazards, thrombolysis within 6 h improved functional outcome. Benefit did not seem to be diminished in elderly patients.

FUNDING: UK Medical Research Council, Health Foundation UK, Stroke Association UK, Research Council of Norway, Arbetsmarknadens Partners Forsakringsbolag (AFA) Insurances Sweden, Swedish Heart Lung Fund, The Foundation of Marianne and Marcus Wallenberg, Polish Ministry of Science and Education, the Australian Heart Foundation, Australian National Health and Medical Research Council (NHMRC), Swiss National Research Foundation, Swiss Heart Foundation, Assessorato alla Sanita, Regione dell'Umbria, Italy, and Danube University.

Original languageEnglish
Pages (from-to)2352-2363
Number of pages12
JournalThe Lancet
Issue number9834
Publication statusPublished - 23 Jun 2012

Bibliographical note

Copyright © 2012 Elsevier Ltd. All rights reserved.

The University of Edinburgh and the Lothian Health Board are cosponsors. The start-up phase was supported by a grant from the Stroke Association, UK. The expansion phase was funded by The Health Foundation UK. The main phase of the trial is funded by the following organisations: UK MRC (grant numbers G0400069 and EME 09-800-15) and managed by NIHR on behalf of the MRC-NIHR partnership; The Research Council of Norway; AFA Insurances (Sweden); the Swedish Heart Lung Fund; The Foundation of Marianne and Marcus Wallenberg; Stockholm County Council and Karolinska Institute Joint ALF-project grants (Sweden); the Government of Poland (grant number 2PO5B10928); the Australian Heart Foundation (grant number G 04S 1638); Australian NHMRC (grant number 457343); the Swiss National Research Foundation; the Swiss Heart Foundation; Foundation for health and cardio-/neurovascular research, Basel, Switzerland; the Assessorato alla Sanita, Regione dell'Umbria; Danube University, Krems, Austria


  • adolescent
  • adult
  • age distribution
  • aged
  • aged, 80 and over
  • brain ischemia
  • double-blind method
  • drug administration schedule
  • female
  • fibrinolytic agents
  • humans
  • infusions, intravenous
  • male
  • middle aged
  • recombinant proteins
  • secondary prevention
  • severity of illness index
  • stroke
  • thrombolytic therapy
  • tissue plasminogen activator
  • treatment outcome
  • young adult


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