Reteplase and non-immunogenic staphylokinase show superior functional outcomes vs alteplase in AIS within 4.5h

This systematic review and network meta-analysis compared the efficacy and safety of intravenous thrombolytic drugs for acute ischemic stroke (AIS) within 4.5 hours of onset. The analysis included 21 randomized controlled trials published up to December 12, 2025, involving a total of 16,837 adult patients. The primary efficacy outcomes were 90-day excellent (modified Rankin Scale [mRS] score 0–1) and good (mRS 0–2) functional outcomes. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and all-cause mortality. A frequentist network meta-analysis using a fixed-effect consistency model was conducted, reporting odds ratios (ORs) with 95% confidence intervals (CIs). For achieving an excellent functional outcome (mRS 0–1), reteplase (18 + 18 mg) showed a statistically significant advantage over alteplase (0.9 mg/kg) (OR 1.60; 95% CI, 1.27–2.02). Non-immunogenic recombinant staphylokinase (10 mg) also demonstrated a statistically significant benefit over the comparator for this outcome (OR 2.23; 95% CI, 1.43–3.48). Reteplase (18 + 18 mg) also improved the likelihood of a good functional outcome (mRS 0–2) compared with alteplase (OR 1.41; 95% CI, 1.08–1.84). Regarding safety, non-immunogenic recombinant staphylokinase significantly reduced the risk of sICH compared with tenecteplase 0.25 mg/kg (OR 0.31; 95% CI, 0.11–0.94). No significant differences in 90-day all-cause mortality were observed among the treatments. The authors concluded that within the 4.5-hour treatment window, reteplase (18 + 18 mg) and non-immunogenic recombinant staphylokinase (10 mg) were associated with the highest probabilities of improved functional outcomes.

Imagine you or a loved one has just had a stroke. In the frantic rush to the hospital, a doctor has to choose which clot-busting drug to give. That single choice could shape your ability to walk, talk, and live independently three months later. A massive review of 21 clinical trials, involving over 16,800 patients, compared all the available drugs given within 4.5 hours of a stroke. The goal was to see which ones help people recover best and which are safest. The findings are striking. Two newer drugs stood out for helping more people achieve an excellent recovery—meaning they could walk and care for themselves with no help. One, called reteplase (given as two 18 mg doses), was better than the standard drug alteplase at helping patients get back to normal. Another, a new version of staphylokinase, showed an even stronger benefit for excellent recovery. On safety, this new staphylokinase also appeared to carry a lower risk of a dangerous brain bleed than one dose of another newer drug, tenecteplase. Importantly, none of the drugs showed a difference in the risk of dying within 90 days. The bottom line is clear: in the race against time after a stroke, the specific medication used is a critical factor for a good outcome.