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PACULit Literature Updates September 2025: Emergency Medicine & Critical Care

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  1. Use of a drug-related problem oriented medical record in the medication review of critically ill patients Randomized clinical trial
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  2. PACULit Daily Literature Update: Stress hyperglycemia ratio as a biomarker for early mortality risk stratification in cardiovascular disease a propensity matched analysis
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  3. PACULit Daily Literature Update: Initial serum electrolyte imbalances and mortality in patients with traumatic brain injury a retrospective study
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  4. PACULit Daily Literature Update: AsNeeded AlbuterolBudesonide in Mild Asthma
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  5. PACULit Daily Literature Update: Thiamine as a metabolic resuscitator after in hospital cardiac arrest
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  6. PACULit Daily Literature Update: The Effect of Early Fluid Resuscitation on Mortality in Sepsis A Systematic Review and Meta Analysis
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  7. PACULit Daily Literature Update: Inhaled isoflurane for sedation of mechanically ventilated children in intensive care (IsoCOMFORT): a multicentre, randomised, active-control, assessor-masked, non-inferiority phase 3 trial
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  8. PACULit Daily Literature Update: Prevalence risk factors and consequences of early clinical deterioration under noninvasive ventilation in emergency department patients a prospective multicentre observational study of the French IRU Network
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  9. PACULit Daily Literature Update: Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock
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  10. Opportunistic Screening for Atrial Fibrillation With Continuous ECG Monitoring in the Emergency Department
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  11. PACULit Daily Literature Update: Efficacy of targeting high mean arterial pressure for older patients with septic shock OPTPRESS a multicentre pragmatic open label randomised controlled trial
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  12. PACULit Daily Literature Update: Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients
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  13. PACULit Daily Literature Update: Andexanet alfa increases 30-day thrombotic events relative to four-factor prothrombin complex concentrate for factor Xa inhibitors related intracerebral hemorrhage in veterans
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  14. PACULit Daily Literature Update: Antibiotic De-Escalation Practices in the Intensive Care Unit A Multicenter Observational Study
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  15. PACULit Daily Literature Update: Fludrocortisone to treat patients with aneurysmal subarachnoid haemorrhage Protocol for an international phase 3 randomised placebocontrolled multicentre trial
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  16. PACULit Daily Literature Update: Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest
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  17. PACULit Daily Literature Update: Real-Time Hemodynamic Responses to Epinephrine and Their Association with ROSC in Out-of-Hospital Cardiac Arrest
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  18. Reevaluating bicarbonate therapy in pediatric DKA A propensity scorematched analysis of neurological and respiratory outcomes
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  19. PACULit Daily Literature Update: Establishing discordance rate of estimated glomerular filtration rate between serum creatinine based calculations and cystatin C based calculations in critically ill patients
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  20. Alteplase for Posterior Circulation Ischemic Stroke at 45 to 24 Hours
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  21. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
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  22. ACPE Required Forms: PACULit Literature Updates September 2025: Emergency Medicine & Critical Care
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Daily Literature Update

Alteplase for Posterior Circulation Ischemic Stroke at 4.5 to 24 Hours

Yan S, Zhou Y, Lansberg MG, et al. Alteplase for Posterior Circulation Ischemic Stroke at 4.5 to 24 Hours. N Engl J Med. 2025;392(13):1288-1296. doi:10.1056/NEJMoa2413344. PMID:40174223.

Introduction

IV alteplase 4.5 to 24 hours post-stroke improves functional independence in mild posterior circulation ischemic stroke patients in a Chinese cohort.

Study Type: Randomized controlled trial

Population: 234 mild posterior circulation stroke patients (median NIHSS 3)

Intervention: IV alteplase 0.9 mg/kg from 4.5 to 24 hours post onset

Outcomes: Functional independence at 90 days, safety (ICH, death)

Key Findings

  • 89.6% functional independence with alteplase vs 72.6% standard care
  • Adjusted risk ratio 1.16 (95% CI, 1.03–1.30), P=0.01
  • Low symptomatic ICH: 1.7% vs 0.9%
  • Lower 90-day mortality: 5.2% vs 8.5%

Context & Related Research

  • Yan et al., 2025: RCT showing significant functional benefit and safety in extended window posterior circulation stroke (PMID:40174223), landmark evidence for clinical practice.
  • TIMS-China registry, 2016: Observational data confirming safety and efficacy of IV alteplase within 4.5 hrs in idiopathic posterior circulation stroke (PMID:27310965), foundational benchmark.
  • Yang et al., 2016: Prospective cohort supporting favorable 90-day outcomes and hemorrhage rates in posterior circulation stroke (PMID:27418829), adding population-specific validation.
  • Li et al., 2024: Predictive modeling study aiding in identifying patients likely to benefit from thrombolysis (PMID:38862629), enhancing patient selection strategies.

Clinical Implications

  • Expand consideration of IV alteplase to 4.5–24 h window in mild posterior circulation strokes not eligible for thrombectomy.
  • Expect improved functional outcomes with low symptomatic hemorrhage risk.
  • Utilize predictive tools and clinical judgment to optimize patient selection.

Strengths & Limitations

Strengths Limitations
Randomized controlled design focused on extended treatment window Limited to mild stroke severity; excludes thrombectomy candidates
Comprehensive safety monitoring; population-specific insights Study population exclusively Chinese; generalizability uncertain

Future Directions

Further trials are needed to assess alteplase use beyond 24 hours, in severe strokes, diverse populations, and versus thrombectomy in posterior circulation ischemic stroke.

Conclusion

Intravenous alteplase administered 4.5 to 24 hours post-stroke significantly improves functional independence at 90 days in selected mild posterior circulation stroke patients with low hemorrhagic risk.

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Citations

  1. Yan S, Zhou Y, Lansberg MG, et al. Alteplase for Posterior Circulation Ischemic Stroke at 4.5 to 24 Hours. N Engl J Med. 2025;392(13):1288-1296. doi:10.1056/NEJMoa2413344. PMID:40174223.
  2. Chen WH, Zhao XQ, et al. TIMS-China registry: safety and efficacy of IV alteplase within 4.5 hours in posterior circulation stroke. Stroke. 2016; PMID:27310965.
  3. Yang J, Xu Y, et al. Prospective cohort outcomes in posterior circulation stroke. Neurology. 2016; PMID:27418829.
  4. Li X, Wang Y, et al. Predictive models for thrombolysis benefit in stroke. J Stroke Cerebrovasc Dis. 2024; PMID:38862629.

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