Abstract Background and aims With rapid population aging in Japan, clinicians increasingly encounter very elderly patients with acute ischemic stroke (AIS), and decisions regarding intravenous recombinant tissue plasminogen activator (iv-rt-PA) therapy in patients aged ≥90 years remain challenging. We investigated the use and outcomes of iv-rt-PA therapy in patients aged ≥90 years admitted to our hospital. Methods Among 17,381 patients with AIS admitted between October 2005 and September 2025, patients aged ≥90 years arrived within the therapeutic time window for rt-PA were retrospectively identified. Patients were classified into rt-PA-treated and non-rt-PA-treated groups, and clinical characteristics and outcomes were compared. Results During the study period, 1,498 patients aged ≥90 years were admitted with AIS, of whom 589 patients (39.3%) arrived within the therapeutic time window for rt-PA. Among these patients, 121 (20.5%) received rt-PA and 467 (79.3%) did not. There were no significant differences between rt-PA and non-rt-PA groups in age (92 vs. 92 years, p=0.508) or NIHSS score at admission (13 vs. 15, p=0.905). Mechanical thrombectomy was performed more frequently in the rt-PA group (26.4% vs. 15.6%, p=0.006). Symptomatic intracerebral hemorrhage (SIH) related to rt-PA was observed in 2.5%. Among patients living at home before onset, discharge home or transfer for rehabilitation was more frequent in the rt-PA group (66.3% vs. 49.7%, p=0.007). Conclusions In patients aged ≥90 years with AIS living at home before onset, iv-rt-PA therapy was associated with a higher rate of favorable discharge outcomes without SIH. Iv-rt-PA may be a reasonable treatment option even in patients aged ≥90 years. Conflict of interest Hiromi Ihoriya. nothing to disclose
Ihoriya et al. (2026) studied this question.