www.thelancet.

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Articles
Stroke treatment with alteplase given 3045 h after onset
of acute ischaemic stroke (ECASS III): additional outcomes
and subgroup analysis of a randomised controlled trial
Erich Bluhmki, ngel Chamorro, Antoni Dvalos, Thomas Machnig, Christophe Sauce, Nils Wahlgren, Joanna Wardlaw, Werner Hacke
Summary
Background In the European Cooperative Acute Stroke Study III (ECASS III), alteplase administered 3045 h after
the onset of stroke symptoms resulted in a signicant benet in the primary endpoint (modied Rankin scale [mRS]
score 01) versus placebo, with no dierence in mortality between the treatment groups. Compared with the 03 h
window, there was no excess risk of symptomatic intracranial haemorrhage. We assessed the usefulness of additional
endpoints and did subgroup and sensitivity analyses to further investigate the benet of alteplase.
Methods In a double-blind, multicentre study in Europe, patients with acute ischaemic stroke were randomly assigned
to intravenous alteplase (09 mg/kg bodyweight) or placebo. Additional outcome analyses included functional
endpoints at day 90 or day 30 (mRS 01 [day 30], mRS 02, Barthel index 85, and global outcome statistic [day 30])
and treatment response (8-point improvement from baseline or 01 score on the National Institutes of Health stroke
scale [NIHSS], and a stratied responder analysis by baseline NIHSS score). The subgroup analyses were based on
the mRS 01 at day 90, symptomatic intracranial haemorrhage, and death. Analyses were by intention to treat and per
protocol. This study is registered with ClinicalTrials.gov, number NCT00153036.
Findings 418 patients were assigned to alteplase and 403 to placebo. Although not signicant in every case, all additional
endpoints showed at least a clear trend in favour of alteplase. Alteplase was eective in various subgroups, including
older patients (<65 years: odds ratio 161, 95% CI 105248; 65 years: 115, 080164; p=0230), and the eectiveness
was independent of the severity of stroke at baseline (NIHSS 09: 128, 084196; NIHSS 1019: 116, 073184;
NIHSS 20: 232, 061890; p=0631). The incidence of symptomatic intracranial haemorrhage seemed to be
independent of previous antiplatelet drug use (no: 241, 109533; yes: 233, 079690; p=0962) and time from onset
of symptoms to treatment (181210 min: 162, 0261025; 211240 min: 197, 082476; 241270 min: 315, 101979;
p=0761), but not of age dichotomised at 65 years (<65 years: 074, 028196; 65 years: 579, 2181539; p=0004).
Interpretation Our results support the use of alteplase up to 45 h after the onset of stroke symptoms across a broad
range of subgroups of patients who meet the requirements of the European product label but miss the approved
treatment window of 03 h.
Funding Boehringer Ingelheim.
Introduction
In the randomised, placebo-controlled European
Cooperative Acute Stroke Study III (ECASS III),
1
we
assessed whether the time window for initiation of
alteplase could be safely increased from the standard 3 h
after the onset of stroke symptoms to up to 45 h. Patients
treated with alteplase had a signicantly better outcome
at day 90 than did controls for the primary endpointie,
a score of 01 on the modied Rankin scale (mRS)and
the secondary endpointie, a global outcome statistic
based on the results of four dichotomised endpoints
(mRS score 01, Barthel index [BI] score 95, National
Institutes of Health stroke scale [NIHSS] score 01, and
the Glasgow outcome scale [GOS] score 1). Mortality rates
were similar in the alteplase and placebo groups, despite
the extended treatment window. As in previous studies
in which thrombolytic treatment was initiated 03 h after
stroke onset,
24
the incidence of intracranial haemorrhage
in ECASS III was signicantly higher with alteplase than
with placebo. However, the absolute number of symp tom-
atic haemorrhages was notably low compared with other
studies.
25
The safety results of ECASS III therefore
indicated no exacerbated risk of intracranial haemorrhage
in the extended time window compared with 03 h.
First, we undertook secondary analyses using dierent
endpoints to conrm or refute the e cacy and safety
outcomes in the primary analysis in ECASS III. Second,
we sought evidence of confounding factors or subgroups
that might dierentially aect treatment outcome.
Additionally, to further investigate the benet of alteplase
noted in the primary analysis, we did various sensitivity
analyses.
Methods
Patients
The study design, patient population, and inclusion and
exclusion criteria have been described previously.
1
Briey,
ECASS III was a double-blind, randomised,
Lancet Neurol 2009;
8: 1095102
Published Online
October 21, 2009
DOI:10.1016/S1474-
4422(09)70264-9
See Reection and Reaction
page 1074
Department of Statistics,
Boehringer Ingelheim,
Biberach, Germany
(E Bluhmki PhD); Functional
Unit of Cerebrovascular
Diseases, Hospital Clinic,
Barcelona, Spain
( Chamorro MD); Department
of Neurosciences, Hospital
Universitari Germans Trias i
Pujol, Barcelona, Spain
(A Dvalos MD); Boehringer
Ingelheim, Ingelheim, Germany
(T Machnig MD); Boehringer
Ingelheim, Reims, France
(C Sauce MS); Department of
Neurology, Karolinska
Institutet, Stockholm, Sweden
(N Wahlgren MD); Division of
Clinical Neurosciences,
SINAPSE Collaboration,
Western General Hospital,
University of Edinburgh, UK
(J Wardlaw MD); and
Department of Neurology,
University of Heidelberg,
Heidelberg, Germany
(W Hacke MD)
Correspondence to:
Werner Hacke, Department of
Neurology, Im Neuenheimer
Feld 400, D-69120 Heidelberg,
Germany
werner.hacke@med.
uni-heidelberg.de
Articles
1096 www.thelancet.com/neurology Vol 8 December 2009
placebo-controlled trial in which patients were enrolled
from several centres across Europe. The eect of alteplase
(09 mg/kg bodyweight, with an upper limit of 90 mg)
intravenously infused over 60 min was compared with
that of placebo on disability and neurological outcomes
in patients treated within 3045 h after the onset of
stroke symptoms. Patients (aged 1880 years) with onset
of clinically conrmed acute ischaemic stroke symptoms
3045 h before initiation of study drug were included
in the study. A cerebral CT scan was required before
randomisation to exclude patients with intracranial
haemorrhage or major ischaemic infarction. Those with
severe stroke (eg, NIHSS score >25) were also excluded.
With the exception of the increased time window,
alteplase was to be used strictly in accordance with the
European Summary of Product Characteristics.
The trial protocol and amendments were accepted by
the European Medicines Agency and were approved by
the institutional review boards of the participating
centres. The protocol was developed in agreement with a
regulatory decision by the European Union Commission
and the steering committee. All patients or legally
authorised representatives provided written informed
consent before enrolment.
Randomisation and masking
Eligible patients were randomly assigned in a 1:1 ratio to
alteplase or placebo. An interactive voice randomisation
system was used, with randomisation at centres done in
blocks of four to ensure a balanced distribution of group
assignments at any time. Knowledge of the size of the
blocks was withheld from the investigators to ensure that
they were unaware of the treatment assignments.
Alteplase and matched placebo were reconstituted from
a lyophilised powder in sterile water for injection.
Outcome measures
The primary (mRS 01), secondary (the global outcome
statistic), some tertiary functional, and safety endpoints
of ECASS III have already been reported.
1
We report the
additional outcomes investigated in ECASS III at 90 days
and 30 days in the intention-to-treat (ITT) and per-protocol
(PP) populations, including outcomes for independence
(mRS score of 02 and BI score 85), and for response
(an 8-point improvement in the NIHSS score from
baseline or a score of 01, or based on a responder
analysis of the mRS stratied by the baseline NIHSS
score). We also analysed functional outcome across the
entire distribution of the mRS scores at day 30, in
accordance with a previously established method.
6
Subgroup analyses
We investigated the e cacy and safety of alteplase in the
ITT population in several predened subgroups (time
from onset of symptoms to treatment [OTT], baseline
NIHSS score, sex, and age) and in subgroups that were
selected post-hoc on the basis of previous clinical research
suggesting dierential e cacy of alteplase in these
subgroups (diabetes, previous stroke, hypertension,
smoking status, previous chronic use of antiplatelet drugs,
and atrial brillation).
7
Subgroup analyses for e cacy
Alteplase
(n=418)
Placebo
(n=403)
Age (years) 649 (122) 656 (110)
Men 264 (63%) 231 (57%)
Weight (kg) 785 (15) 780 (16)
Baseline NIHSS 107 (56) 116 (59)
Median (IQR) 9 (615) 10 (716)
Systolic blood pressure (mm Hg) 1526 (192) 1533 (221)
Diastolic blood pressure (mm Hg) 844 (135) 839 (136)
Diabetes 62 (15%) 67 (17%)
Previous use of antiplatelet drugs 130 (31%) 131 (33%)
Hypertension 261 (62%) 253 (63%)
Atrial utter/brillation 53 (13%) 55 (14%)
History of stroke 32 (8%) 57 (14%)
Smoking status*
Never smoked 203 (49%) 186 (46%)
Ex-smoker 86 (21%) 99 (25%)
Current smoker 128 (31%) 116 (29%)
Time to treatment initiation (min;
median, IQR)
239 (225255) 238 (225257)
Time to treatment (min)
180210 40 (10%) 42 (10%)
211240 191 (46%) 193 (48%)
241270 174 (42%) 148 (37%)
Data are mean (SD) or number (%), unless otherwise indicated. NIHSS=National
Institutes of Health stroke scale. *Data were not available for one patient in the
alteplase group and two in the placebo group. Percentages do not add up to
100% because the exact time of treatment initiation was not available for
12 patients in the alteplase group and 15 in the placebo group (one patient was
treated within 3 h); additionally, treatment was initiated after 45 h in one patient
in the alteplase group and ve in the placebo group.
Table 1: Demographic and baseline characteristics of the patients,
by treatment group
821 enrolled and randomly assigned
418 assigned to alteplase*
43 excluded from PP analysis
12 no treatment received
4 uncontrolled hypertension
10 age
10 CT violation
1 outside time window
6 other
48 excluded from PP analysis
13 no treatment received
13 uncontrolled hypertension
6 age
7 CT violation
7 outside time window
2 other
403 assigned to placebo
375 given alteplase
ITT population
PP cohort 355 given placebo
Figure 1: Trial prole
ITT=intention to treat. PP=per protocol. Includes *13 and ten patients lost to follow-up, with imputation of worst
possible outcome for the primary endpoint.
Articles
www.thelancet.com/neurology Vol 8 December 2009 1097
mRS score 01
mRS score 01 (adjusted nal model*)
mRS score 01 (adjusted full model)
BI score 95
NIHSS score 01
GOS score 1
Global outcome statistic (unadjusted)
Global outcome statistic (adjusted nal model*)
mRS score 02
BI score 85
Responder analysis of the mRS at day 90
stratied by the NIHSS score at baseline
NIHSS=8-point improvement from
baseline, or score 01
mRS score 01
mRS score 01 (adjusted nal model*)
mRS score 01 (adjusted full model)
BI score 95
NIHSS score 01
GOS score 1
Global outcome statistic (unadjusted)
Global outcome statistic (adjusted nal model*)
mRS score 02
BI score 85
Responder analysis of the mRS at day 30
stratied by the NIHSS score at baseline
NIHSS=8-point improvement from
baseline, or score 01
52% (219)
..
..
63% (265)
50% (210)
51% (213)
..
..
67% (278)
69% (288)
43% (178)
..
45% (182)
..
..
59% (236)
43% (174)
45% (183)
..
..
62% (248)
66% (265)
38% (152)
..
134 (102176)
142 (102198)
143 (102200)
123 (093162)
133 (101175)
125 (095164)
128 (100165)
138 (104183)
124 (093165)
115 (086154)
122 (093162)
..
0038
0037
0040
0156
0043
0112
0048
0027
0138
0337
0155
..
45% (188)
..
..
56% (236)
45% (188)
..
..
..
59% (245)
60% (251)
33% (139)
58% (244)
36% (147)
..
..
50% (202)
35% (141)
..
..
..
53% (213)
56% (226)
29% (116)
51% (205)
142 (108188)
144 (104199)
129 (098170)
152 (115201)
141 (110180)
144 (109191)
126 (096166)
118 (089155)
123 (092166)
135 (103178)
0013
0026
0069
0004
0007
0010
0097
0249
0167
0031
47% (176)
..
..
59% (220)
47% (177)
..
..
..
61% (227)
62% (234)
34% (128)
61% (230)
38% (134)
..
..
51% (182)
36% (128)
..
..
..
54% (191)
56% (200)
30% (106)
52% (185)
146 (109196)
143 (103200)
135 (101181)
159 (118213)
146 (113190)
144 (108193)
132 (098177)
129 (096173)
122 (089166)
146 (109196)
0012
0035
0045
0002
0004
0013
0066
0096
0216
0012
55% (206)
..
..
66% (248)
53% (197)
53% (200)
..
..
69% (260)
72% (270)
45% (167)
..
45% (161)
..
..
59% (211)
44% (155)
46% (165)
..
..
62% (221)
67% (239)
37% (133)
..
147 (110197)
151 (107213)
153 (107217)
133 (099180)
143 (107191)
132 (098176)
139 (107180)
142 (106192)
137 (101186)
125 (091171)
134 (100180)
..
0010
0019
0018
0061
0017
0064
0015
0020
0044
0169
0052
..
Alteplase
(n=418)
Placebo
(n=403)
Intention-to-treat population Per-protocol population
Odds ratio
(95% CI)
p value Alteplase
(n=375)
Placebo
(n=355)
Odds ratio
(95% CI)
p value
Favours placebo Favours alteplase Favours placebo Favours alteplase
10 10
A
B
Alteplase
(n=418)
Placebo
(n=403)
Intention-to-treat population Per-protocol population
Odds ratio
(95% CI)
p value Alteplase
(n=375)
Placebo
(n=355)
Odds ratio
(95% CI)
p value
Figure 3: Functional e cacy endpoints at day 90 (A) and day 30 (B) after treatment in the intention-to-treat and per-protocol populations
Data are number (%), unless otherwise indicated. E cacy results that have not previously been reported are highlighted grey. p values are not adjusted for multiple testing. mRS=modied Rankin
scale. BI=Barthel index. NIHSS=National Institutes of Health stroke scale. GOS=Glasgow outcome scale. *Adjusted for treatment, baseline NIHSS score, smoking history, stroke onset to treatment time,
and previous hypertension. Adjusted for NIHSS at baseline (5 points), age (by 10 years), weight, onset to treatment time every 15 min, diastolic and systolic blood pressure, dose in mg/kg
bodyweight, smoking status, previous stroke, previous diabetes, atrial brillation, hypertension, previous use of antiplatelet drugs, and sex. Response was dened as mRS=0 for NIHSS <8; mRS 01 for
NIHSS 814; and mRS 02 for NIHSS >14. No data were gathered at day 30.
Alteplase
Placebo
60
50
40
30
66
62
169
148
85
77 77
76
21
40
20
10
0
P
r
o
p
o
r
t
i
o
n

o
f

p
a
t
i
e
n
t
s

(
%
)
10
12
30 30
68
70
123 123
77
49
98
104
180195 05 610 1115
NIHSS score at baseline
1620 >20 196210 211225 226240
Time (min) from stroke onset to treatment initiation
241255 256
A B
Figure 2: Distribution of National Institutes of Health stroke scale (NIHSS) scores at baseline (A) and time from stroke onset to treatment initiation (B)
In (B), patient numbers do not add up to the alteplase and placebo group totals of 418 and 403, respectively, because the exact time of treatment initiation was not
available for 12 patients in the alteplase group and 15 in the placebo group.
Articles
1098 www.thelancet.com/neurology Vol 8 December 2009
were done for the primary endpoint, and those for safety
were done for mortality and symptomatic intracranial
haemorrhage. To allow for improved statistical power of
the subgroup analysis of symptomatic intracranial
haemorrhage, this event was dened according to the
criteria used in the National Institute of Neurological
Disorders and Stroke (NINDS) recombinant tissue
plasminogen activator stroke trialie, a haemorrhage was
considered to be symptomatic if it had not been seen on a
previous CT scan but there was subsequently a suspicion
of haemorrhage or any decline in neurological status.
2
The
incidence of symptomatic intracranial haemorrhage in
the ITT population with this and various other denitions
was reported previously.
1
All subgroup analyses were done
for day 90 outcomes in the ITT and PP populations.
Sensitivity analyses
Several covariate-adjusted logistic regression analyses of
the primary endpoint and an adjusted global odds ratio
(OR) test for the secondary endpoint were done post-hoc
to take into account any numerical imbalances in the
baseline variables, which might have potentially
confounded the results. Furthermore, we investigated
whether the results for favourable outcome as assessed
by mRS scores 01 and NIHSS scores 01 were aected
by stroke severity at baseline, using a type of matched
subgroup analysis described previously.
8
In principle,
this method of classication excludes the subgroups with
baseline NIHSS imbalances to adjust for confounded
results.
8,9
Statistical analysis
The ITT analyses of additional outcomes included all
randomly assigned patients, whether they were treated or
not. When data were missing for outcome among
patients known to be alive, the worst possible outcome
score was assigned. For baseline NIHSS, the best possible
score was imputed; for all other baseline parameters, no
imputation was made. Between-group dierences for all
binary endpoints were calculated with the
2
test for
proportions (with a two-sided of 5%). 95% CIs were
calculated for ORs. For the secondary endpoint, the
global OR test was used with a 95% CI.
For the stratied responder analysis, we dened the
number of responders on the basis of their day 90 and
day 30 mRS scores, stratied according to baseline
NIHSS severity. The distribution analysis of the mRS
scores was analysed by means of the Cochran
MantelHaenszel test, with adjustment for the baseline
score on the NIHSS and for the time between the onset
of symptoms and initiation of treatment.
We analysed treatment-by-subgroup interaction in the
ITT population using logistic regression with treatment
as the main eect, and subgroup and treatment-by-
subgroup as covariates for calculation of the p value for
interaction. ORs for the treatment eect with their
95% CIs were calculated for each subgroup separately.
Alteplase
(n=418)
94 (22%) 94 (22%) 57 (14%) 45 (11%) 49 (12%) 56 (13%)
23
(6%)
22
(5%)
Number of patients (%)
0
p=0013
59 (15%) 64 (16%) 45 (11%) 66 (16%) 86 (21%) 61 (15%)
87 (23%)
0 1 2 3 4 5 6
p=0013 89 (24%) 51 (14%) 44 (12%) 43 (11%) 43 (11%)
18
(5%)
16
(5%)
47 (13%) 62 (17%) 39 (11%) 57 (16%) 78 (22%) 56 (16%)
20 40 60 80 100
Score 0 1 2 3 4 5 6
Placebo
(n=403)
Alteplase
(n=375)
Score
Placebo
(n=355)
A
B
Figure 4: Distribution of scores on the modied Rankin scale at day 30 for the intention-to-treat (A) and
per-protocol (B) populations
The stratied analysis of the score distribution was compared by use of the CochranMantelHaenszel test, with
adjustment for the baseline score on the National Institutes of Health stroke scale and for the time between the
onset of stroke symptoms and initiation of treatment.
Age (years)
<65
65
Sex
Male
Female
NIHSS at baseline
09
1019
20
Time to treatment initiation (min)
181210
211240
241270
Previous diabetes
No
Yes
History of stroke
No
Yes
Hypertension
No
Yes
Arial utter or brillation
No
Yes
Smoking history
Non-smoker
Current smoker
Ex-smoker
Previous chronic use of antiplatelet drugs
No
Yes
ITT population
57% (105/184)
49% (114/234)
53% (139/264)
52% (80/154)
73% (156/215)
34% (57/166)
16% (6/37)
58% (23/40)
49% (93/191)
56% (98/174)
54% (191/356)
45% (28/62)
52% (199/386)
63% (20/32)
57% (90/157)
49% (129/261)
56% (205/365)
26% (14/53)
54% (110/203)
52% (67/128)
49% (42/86)
52% (151/288)
52% (68/130)
52% (219/418)
45% (70/155)
45% (112/247)
42% (97/231)
50% (85/171)
67% (128/190)
31% (50/161)
8% (4/52)
40% (17/42)
47% (91/193)
43% (64/148)
44% (149/335)
49% (33/67)
47% (163/345)
33% (19/57)
44% (66/149)
46% (116/253)
47% (163/347)
35% (19/55)
48% (89/186)
39% (45/116)
47% (47/99)
46% (125/271)
44% (57/131)
45% (182/403)
161 (105248)
115 (080164)
154 (108219)
109 (071169)
128 (084196)
116 (073184)
232 (061890)
199 (083479)
106 (071159)
169 (109263)
145 (107195)
085 (042170)
119 (089159)
333 (135822)
169 (107266)
115 (082163)
145 (108194)
068 (030155)
129 (087192)
173 (104288)
106 (059188)
129 (092180)
142 (087232)
134 (102176)
0230
0237
0631
0212
0167
0033
0190
0092
0435
0738
0038
Alteplase Placebo Odds ratio (95% CI) Odds ratio (95% CI) p value
10
Favours alteplase Favours placebo
Figure 5: Subgroup analysis of favourable outcome (modied Rankin scale 01) at day 90 according to
demographic characteristics, baseline clinical data, and past medical history
Dashed vertical line represents the odds ratio for the whole intention-to-treat (ITT) population. Data are % (n/N),
unless otherwise indicated. p values are for interaction based on logistic regression model with treatment,
subgroup, and interaction term. NIHSS=National Institutes of Health stroke scale.
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www.thelancet.com/neurology Vol 8 December 2009 1099
We did several adjusted logistic regression analyses for
investigation of the sensitivity of the primary endpoint.
These analyses are referred to as the nal model, which
included all baseline variables that previously remained
signicant at p<01 in a multivariate model. Thus,
treatment, baseline NIHSS, smoking history, OTT, and
previous hypertension were retained. The results of the
analyses adjusted for these variables in the ITT population
have already been reported.
1
To show the robustness of the
nal model, we also calculated the estimated ORs (alteplase
vs placebo) and their 95% CIs and p values (Wald
2
test)
for the full model, which included all known and available
prognostic risk factorsnamely, NIHSS severity at
baseline, age, weight, OTT, blood pressure, treatment dose,
smoking status, previous stroke, previous diabetes, atrial
brillation, hypertension, previous use of antiplatelet
drugs, and sex. The C statistic was recorded to compare the
predictive ability of the models. For the PP population, the
same statistical tests were applied as for the ITT population.
No subgroup analyses were done for the PP set.
This study is registered with ClinicalTrials.gov, number
NCT00153036.
Role of the funding source
The study protocol was developed by the sponsor in
agreement with a regulatory decision by the European
Union Commission and the steering committee for the
ECASS III trial. The sponsor was responsible for
operational aspects of the trial, including data gathering,
storage, and analysis. Statistical analyses were done
simultaneously by an independent external statistician and
the statistician for the sponsor. The corresponding author
had full access to all the data in the study, and the decision
to submit the report for publication was taken by the lead
investigator in agreement with the steering committee.
Results
We enrolled 821 patients from July, 2003, to November,
2007, and randomly assigned 418 to the alteplase group
and 403 to the placebo group. Figure 1 shows the trial
prole.
Table 1 shows the baseline demographic and clinical
characteristics of the two groups. These were well balanced
between groups, although there were numerical dierences
in stroke severity and the presence or absence of previous
stroke. The distribution of the NIHSS score at baseline by
5-point categories was similar in both groups (gure 2A),
showing that the imbalance in the NIHSS at baseline was
simply due to fewer patients with a severe stroke (NIHSS
>20) in the alteplase than in the placebo group. The median
OTT was similar in the alteplase and placebo groups. The
pattern of distribution of treatment onset by 15-min
categories was similar in both groups, except for the
241255-min window, which included more individuals
treated with alteplase than with placebo (gure 2B).
Functional independence (mRS 02) was improved
with alteplase versus placebo at day 90. The dierence
between the groups was not signicant in the ITT
population (p=0138) but was in the PP population
(p=0044; gure 3A).
Signicant benets in favour of alteplase were noted as
early as day 30 for the neurological score in the ITT and
PP populations as assessed by an NIHSS score of 01
and the global outcome statistic (gure 3B). For a BI of at
least 95, no signicant treatment eect was noted, except
for the PP analysis at day 30 (gure 3B).
Day 30 functional response to treatment (improvement
of 8 points on the NIHSS scale or achieving a score of 01)
was signicantly better in the alteplase than in the placebo
group (gure 3B). On the stratied responder analysis, a
clear non-signicant pattern in favour of the alteplase-
treated group was noted but this was not signicant.
The distribution analysis across all scores of the mRS
showed that patients treated with alteplase shifted
towards a better health state by day 30 than did
placebo-treated patients, with an mRS of 01 in more
alteplase-treated individuals than in placebo-treated
patients (gure 4). This shift was signicant in the ITT
and PP populations (gure 4).
3% (6/184)
11% (26/234)
9% (25/264)
5% (7/154)
3% (6/215)
11% (18/166)
22% (8/37)
5% (2/40)
9% (18/191)
7% (12/174)
7% (25/356)
11% (7/62)
8% (30/386)
6% (2/32)
7% (11/157)
8% (21/261)
5% (20/365)
23% (12/53)
8% (17/203)
4% (5/128)
12% (10/86)
7% (21/288)
8% (11/130)
8% (32/418)
8% (12/155)
9% (22/247)
7% (17/231)
10% (17/171)
1% (2/190)
13% (21/161)
21% (11/52)
12% (5/42)
9% (18/193)
5% (8/148)
8% (27/335)
10% (7/67)
8% (27/345)
12% (7/57)
9% (13/149)
8% (21/253)
7% (26/347)
15% (8/55)
7% (13/186)
13% (15/116)
6% (6/99)
8% (21/271)
10% (13/131)
8% (34/403)
040 (015110)
128 (070233)
132 (070251)
043 (017107)
270 (0541353)
081 (041159)
103 (037287)
039 (007213)
101 (051201)
130 (052326)
086 (049152)
109 (036331)
099 (058171)
048 (009244)
079 (034182)
097 (051182)
072 (039131)
172 (064462)
122 (057258)
027 (010078)
204 (071587)
094 (050176)
084 (036195)
090 (054149)
0052
0050
0400
0476
0710
0403
0703
0138
0020
0838
0681
Age (years)
<65
65
Sex
Male
Female
NIHSS at baseline
09
1019
20
Time to treatment initiation (min)
181210
211240
241270
Previous diabetes
No
Yes
History of stroke
No
Yes
Hypertension
No
Yes
Arial utter or brillation
No
Yes
Smoking history
Non-smoker
Current smoker
Ex-smoker
Previous chronic use of antiplatelet drugs
No
Yes
ITT population
Alteplase Placebo Odds ratio (95% CI) Odds ratio (95% CI) p value
10
Favours alteplase Favours placebo
Figure 6: Subgroup analysis of mortality according to demographic characteristics, baseline clinical data,
and past medical history
Dashed vertical line represents the odds ratio for the whole intention-to-treat (ITT) population. Data are % (n/N),
unless otherwise indicated. p values are for interaction based on logistic regression model with treatment,
subgroup, and interaction term. NIHSS=National Institutes of Health stroke scale.
Articles
1100 www.thelancet.com/neurology Vol 8 December 2009
Figures 57 show the results of the ITT subgroup
analyses. With the exception of the presence or not of
previous stroke, no signicant subgroup-by-treatment
interactions were noted (p<005) for the primary
endpoint (mRS 01) at day 90. Both subgroups beneted
from alteplase treatment, but patients who previously
had a stroke seemed to benet signicantly more than
those who had not had a previous stroke (gure 5). In
nearly all subgroups, there was a clear uniform
pattern favouring alteplase, indicated by the fact that the
OR was greater than 1 but p values for interaction (based
on logistic regression with treatment, subgroup, and the
interaction term) were non-signicant (gure 5).
Generally, the analysis of mortality in subgroups
showed random variation of the point estimate around
the line of identity. No signicant subgroup-by-treatment
interactions were noted, except for current smoking
(gure 6), which seemed to have a protective eect.
For the occurrence of symptomatic intracranial
haemorrhage, no signicant subgroup-by-treatment
interactions were noted, except for age (gure 7).
Treatment with alteplase remained signicant for a
favourable outcome in the ITT analysis of the primary
endpoint adjusted according to the full and nal model
(table 2). Adjustment according to the full model generated
similar results to those of the nal model (table 2). In the
adjusted analysis of the ITT population, comparison of the
C statistic values indicated that both models had the same
predictive ability in correctly classifying 80% of patients
with respect to outcome. C statistic values for the PP
population were similar. For the ITT and PP populations,
the results obtained with both adjusted models conrmed
the robustness of the unadjusted treatment eect, showing
roughly a 14-fold increased chance of benet after alteplase
treatment (gure 3A).
Table 3 shows the eect of baseline stroke severity on
stroke outcome at day 90. In the category of severe strokes
(NIHSS 20) in the ITT population, for example, the
e cacy of alteplase still held true with absolute benets
in mRS 01 (85%) and NIHSS 01 (58%), indicating
that the overall benet of alteplase was not caused by
NIHSS baseline imbalances (table 3).
Discussion
Almost all our additional outcome analyses strongly
support the positive primary and secondary trial results
of ECASS III.
1
Although not signicant in every analysis,
all additional e cacy endpoints showed at least a clear
pattern in favour of alteplase. The consistent treatment
eects noted across nearly all subgroup analyses and all
sensitivity analyses of the primary endpoint were also
consistent with the eects noted in the overall population.
In particular, within the severity range of index strokes
included in ECASS III, we conrmed that alteplase was
eective in all patients with acute stroke, independent of
their stroke severity at baseline.
The lack of signicance for some of the additional
e cacy outcomes, although most likely due to sample
size and chance, might partly also be attributed to the
specic measure of stroke assessment that was used.
15,16
n C statistic Odds ratio (95% CI) p value
Unadjusted
ITT 821 05361 134 (102176) 0038
PP 730 05479 147 (110197) 0010
Full model (all known and available prognostic factors*)
ITT 784 08017 143 (102200) 0040
PP 722 08002 153 (107217) 0018
Final model (NIHSS at baseline, OTT, smoking, hypertension)
ITT 785 07955 142 (102198) 0037
PP 722 07924 151 (107213) 0019
p values for Wald test. ITT=intention to treat. PP=per protocol. OTT=onset of
symptoms to treatment time. *National Institutes of Health stroke scale (NIHSS) at
baseline (5 points), age (by 10 years), weight, OTT per 15 min, diastolic and systolic
blood pressure, dose in mg/kg bodyweight, smoking status, previous stroke,
previous diabetes, atrial brillation, hypertension, previous use of antiplatelet drugs,
and sex. NIHSS at baseline (05, 610, 1115, 1620, >20). OTT every 15 min.
Table 2: Adjusted analysis of favourable outcome (modied Rankin
scale 01) according to the nal and full models of adjustment
Age (years)
<65
65
Sex
Male
Female
NIHSS at baseline
09
1019
20
Time to treatment initiation (min)
181210
211240
241270
Previous diabetes
No
Yes
History of stroke
No
Yes
Hypertension
No
Yes
Arial utter or brillation
No
Yes
Smoking history
Non-smoker
Current smoker
Ex-smoker
Previous chronic use of antiplatelet drugs
No
Yes
ITT population
4% (8/184)
11% (25/234)
9% (25/264)
5% (8/154)
5% (10/215)
11% (19/166)
11% (4/37)
8% (3/40)
8% (15/191)
8% (14/174)
8% (28/356)
8% (5/62)
9% (33/386)
0% (0/32)
8% (12/157)
8% (21/261)
7% (24/365)
17% (9/53)
10% (21/203)
5% (6/128)
7% (6/86)
7% (22/288)
8% (11/130)
8% (33/418)
6% (9/155)
2% (5/247)
3% (8/231)
4% (6/171)
2% (3/190)
6% (9/161)
4% (2/52)
5% (2/42)
4% (8/193)
3% (4/148)
3% (11/335)
4% (3/67)
3% (11/345)
5% (3/57)
5% (8/149)
2% (6/253)
3% (10/347)
7% (4/55)
3% (5/186)
3% (3/116)
6% (6/99)
3% (9/271)
4% (5/131)
3% (14/403)
074 (028196)
579 (2181539)
292 (129660)
151 (051444)
304 (0821122)
218 (096498)
303 (0521750)
162 (0261025)
197 (082476)
315 (101979)
251 (123514)
187 (043818)
284 (141571)
..
146 (058368)
360 (143908)
237 (112504)
261 (075906)
418 (1541132)
185 (045758)
116 (036375)
241 (109533)
233 (079690)
238 (125452)
0004
0340
0889
0761
0724
0966
0175
0250
0898
0006
0962
Alteplase Placebo Odds ratio (95% CI) Odds ratio (95% CI) p value
10
Favours alteplase Favours placebo
Figure 7: Subgroup analysis of symptomatic intracranial haemorrhage according to demographic
characteristics, baseline clinical data, and past medical history
Dashed vertical line represents the odds ratio for the whole intention-to-treat (ITT) population. Data are % (n/N),
unless otherwise indicated. p values are for interaction based on logistic regression model with treatment,
subgroup, and interaction term. NIHSS=National Institutes of Health stroke scale.
Articles
www.thelancet.com/neurology Vol 8 December 2009 1101
Indirectly, the results have validated and replicated the
clinical evidence for alteplase obtained in the NINDS
trial in the 03 h window.
2
Our results also support the
ndings of two meta-analyses and the observational SITS
registry study, which all suggested a benet with alteplase
in an extended treatment time window.
1214
As with
the subgroup analyses in the NINDS trial in the 03 h
window,
4,17
we did not nd evidence of a harmful
subgroup-by-treatment interaction on e cacy in patients
treated with alteplase during the 3045 h time window.
Our results from the subgroup analyses of mortality and
symptomatic intracranial haemorrhage in ECASS III
were also broadly consistent with previous evidence from
randomised trials
4
and observational data,
5
and we did
not identify any new risk groups among those that we
classied at trial entry. As for any subgroup analysis, the
results should be interpreted with caution and regarded
mainly as hypothesis-generating because the study was
not powered for condent subgroup analyses.
Several ndings merit discussion. Although older
patients (65 years) beneted from thrombolysis
(gure 5), they also had a higher likelihood of developing
sympto matic intracranial haemorrhage than did younger
patients (gure 7). Increase in age has been associated
with an increased rate of symptomatic intracranial
haemorrhage,
7,10,11
but the association is not clear.
The benet to risk ratio of alteplase across all important
trials (NINDS, ECASS,
13
Alteplase Thrombolysis for
Acute Noninterventional Therapy in Ischemic Stroke
[ATLANTIS], and Safe Implementation of Thrombolysis
in Stroke-Monitoring Study [SITS-MOST]) remains
positive across a range of ages.
18
Age and not treatment
with alteplase was identied as a predictor of negative
outcome in an analysis of ve important stroke trials;
19

and older age was associated with poor outcome but was
not an independent predictor of symptomatic intracranial
haemorrhage in the multivariate analyses of the
SITS-MOST registry data.
7
Also, the risk of symptomatic
intracranial haemorrhage after thrombolysis for stroke in
patients aged at least 80 years seems to be similar to that
in younger patients and in untreated age-matched historic
controls, indicating that bleeding complications are
unlikely to outweigh the potential benet of throm bolytic
treatment in elderly patients.
20
Data from stroke studies
that are in progress and that have no upper age limit, such
as IST-3,
21
are expected to provide further insight into the
net benet of thrombolytic treatment with age.
Our nding that treatment e cacy was independent of
baseline stroke severity corresponds with previous
ndings by the NINDS investigators, who reported no
interaction of baseline stroke severity and treatment
e cacy in a multivariable analysis.
22
Although our results
might lend some support to not ruling out the treatment
of patients with a severe index stroke, this support is
limited by the small sample size in our subgroups and
the fact that patients with severe stroke were excluded
from ECASS III.
A history of stroke seemed to aect functional outcome
advantageously in ECASS III. However this nding,
which is in contrast to evidence from previous stroke
trials, is probably linked to the small sample size.
We noted an apparent protective eect of smoking
against mortality in the alteplase group. This eect has
been noted before in patients given thrombolytic drugs
for acute stroke or myocardial infarction.
23,24
Increased
platelet activation or aggregation and high concentrations
of circulating brinogen and thrombin in smokers are
thought to tilt the pathogenesis of vascular occlusion
further towards thrombogenesis than atherogenesis,
thus increasing the susceptibility of cerebral thrombi to
undergo brinolysis.
Various sensitivity analyses adjusted for dierent
covariates and a matched subgroup analysis specically
designed for investigation of the eect of stroke severity
at baseline showed that the treatment eects of alteplase
were independent of any imbalances of baseline variables
Baseline severity Outcome at day 90
Alteplase Placebo mRS 01 NIHSS 01 Global outcome statistic
Alteplase Placebo Dierence Unadjusted OR
(95% CI)
Alteplase Placebo Dierence Unadjusted OR
(95% CI)
Unadjusted OR (95% CI)
ITT*
09 215 (51%) 190 (47%) 156 (73%) 128 (67%) 52% 128 (084196) 150 (70%) 126 (66%) 35% 117 (077178) 112 (077164)
1019 166 (40%) 161 (40%) 57 (34%) 50 (31%) 33% 116 (073184) 55 (33%) 44 (27%) 58% 132 (082212) 115 (077171)
20 37 (9%) 52 (13%) 6 (16%) 4 (8%) 85% 232 (061890) 5 (13%) 4 (8%) 58% 188 (047752) 176 (044715)
PP
09 197 (53%) 171 (48%) 148 (75%) 115 (67%) 79% 147 (093-232) 142 (72%) 113 (66%) 60% 133 (085-207) 129 (086-192]
1019 150 (40%) 137 (39%) 53 (35%) 42 (31%) 47% 124 (075-203) 52 (35%) 38 (28%) 69% 138 (084-229) 119 (078-182)
20 28 (7%) 47 (13%) 5 (18%) 4 (9%) 93% 234 (057-956) 3 (11%) 4 (9%) 22% 129 (027-624) 168 (046-607)
Data are number (%) or %, unless otherwise indicated. mRS=modied Rankin scale. NIHSS=National Institutes of Health stroke scale. OR=odds ratio. *ITT population: 418 in the alteplase group and 403 in the
placebo group. PP population: 375 in the alteplase group and 355 in the placebo group.
Table 3: Outcomes at day 90 by endpoint according to stroke severity at baseline in the intention-to-treat (ITT) and per-protocol (PP) populations
Articles
1102 www.thelancet.com/neurology Vol 8 December 2009
and consistent across various patient subgroups. Thus,
alteplase signicantly improved clinical outcomes,
without raising additional safety concerns, in patients
treated for acute ischaemic stroke within 3045 h after
the onset of symptoms.
In conclusion, our results support the use of this
thrombolytic drug in the extended period across a broad
range of patient subgroups who meet the requirements
of the European product label but miss the approved
treatment window of 03 h. Even with these encouraging
ndings, the most important principle of acute stroke
intervention should, however, not be lostie, time
remains critical and fast treatment still provides the
greatest chance of recovery.
Contributors
EB, TM, and CS were members of the ECASS III trial management
team at Boehringer Ingelheim. EB, TM, and NW conceived and
designed the research. EB did the statistical analysis, interpreted the
data, prepared the rst draft of the report, coordinated the distribution of
the report among the co-authors, and collated feedback from co-authors
in subsequent drafts. EB, C, AD, TM, NW, JW, and WH made crucial
revisions to the report for important intellectual content. C acquired
data for ECASS III at one of the Spanish centres contributing to the trial.
AD and NM were members and WH was the chairman of the steering
committee. AD assisted in the trial design and interpreted the data. TM,
CS, NW, and JW analysed and interpreted the data. CS was the trial
statistician and validated the statistical programming. NW and WH
acquired the data. JW was a member of the safety outcome adjudication
committee for ECASS III, contributed to the initial trial design (design
of brain scan interpretation), and provided independent interpretation of
scans blinded to patient data. WH designed the trial protocol (endpoint
selection) and contributed to the rst draft of the report.
ECASS III investigators
Steering Committee: W Hacke (chair), A Dvalos, M Kaste,
R von Kummer, V Larrue, D Toni, N Wahlgren.
Data and Safety Monitoring Board: K R Lees (chair), W-D Heiss,
E Lesare, J M Orgogozo.
Safety Outcome Adjudication Committee: R von Kummer (chair),
S Bastianello, J M Wardlaw.
Conicts of interest
EB, TM, and CS are employees of Boehringer Ingelheim. C has
received honoraria from Boehringer Ingelheim. AD has received
honoraria from Boehringer Ingelheim in his capacity as a member of
the steering committee. NW has received consulting and lecture fees
from Boehringer Ingelheim, and his institution has received grant
support from Boehringer Ingelheim. JW has interpreted brain scans
from ECASS III, for which her institution received payment from
Boehringer Ingelheim. WH has received consulting and lecture fees
from Boehringer Ingelheim, and honoraria from Boehringer Ingelheim
in his capacity as chairman of the steering committee.
Acknowledgments
ECASS III was funded by Boehringer Ingelheim. JW was funded by
the Scottish Funding Council through the SINAPSE initiative (Scottish
Imaging Network, A Platform for Scientic Excellence). We thank the
members of the dierent study committees of ECASS III, particularly
W-D Heiss for his important appraisal and review of the report, and are
indebted to him for his tireless support and encouragement. We thank
G Biegert for statistical programming support and A Lemonidis for
editorial assistance.
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