Key result
CT perfusion-guided late thrombolysis achieves similar 90-day functional outcomes to standard early care.
Why the study?
Real-world data on the safety and efficacy of CT perfusion-guided intravenous thrombolysis in patients with wake-up stroke, stroke of unknown time of onset, or onset beyond 4.5 h from last-seen-normal were limited.
Does CT perfusion-guided intravenous thrombolysis with alteplase beyond 4.5 hours from stroke onset achieve similar functional outcomes and safety compared to standard thrombolysis within 4.5 hours?
Cohort (n=657)
Does CT perfusion-guided intravenous thrombolysis with alteplase beyond 4.5 hours from stroke onset achieve similar functional outcomes and safety compared to standard thrombolysis within 4.5 hours?
Real-world cohort data support that CT perfusion-guided intravenous alteplase beyond 4.5 hours or in unknown-onset stroke has comparable safety and 90-day functional outcomes to standard window thrombolysis.
Answers are grounded in this paper and cite their sources.
Does not warrant practice change for extended-window thrombolysis; leaves open comparable outcomes hypothesis for randomized confirmation.
INTRODUCTION: The benefit of intravenous thrombolysis (IVT) in wake-up stroke (WUS), stroke of unknown time of onset (SUKO), or when time exceeds 4.5 h from last-seen-normal (LSN) guided by CT perfusion (CTP) or MRI has been recently suggested. However, there is limited information of IVT in those patients in real-world studies. OBJECTIVE: Our aim was to evaluate safety and efficacy of IVT selected by CTP in patients with WUS, SUKO, or stroke of time onset beyond 4.5 h. MATERIAL AND METHODS: We studied a prospective cohort of patients who underwent IVT from January 2010 to December 2017. Two groups were defined: standard of care group (SC) included patients with time onset <4.5 h and CTP group included patients with WUS, SUKO, or onset beyond >4.5 h from LSN with penumbra area in CTP. We evaluated baseline characteristics, functional outcomes according to modified Rankin Scale (mRS) at discharge and at 90 days, and intracranial hemorrhages rates. RESULTS: 657 patients were studied: 604 (92%) were treated in the SC group and 53 (8%) in the CTP group. The mean NIHSS score was 9.8 in the CTP group versus 13 in the SC group (p = 0.001). Seventeen patients in the CTP group (32.1%) received bridging therapy with mechanical thrombectomy (MT). Last time seen well-to-needle time was 538 versus 155 min (p < 0.001). The incidence of symptomatic intracranial hemorrhage was equal in both groups (3.8 vs. 3.8%, p = 1). Good functional outcome (mRS < 2) was achieved in both groups (72 vs. 60.4%, p = 0.107). CONCLUSIONS: IVT in patients with WUS, SUKO, or stroke beyond >4.5 h from LSN, with salvageable brain tissue on CTP, seems to be safe and has similar functional outcomes at 90 days to the standard therapeutic window, even when combined with MT.
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Medina-Rodríguez et al. (2020) conducted a cohort in Acute ischemic stroke (wake-up stroke, stroke of unknown time of onset, or onset >4.5 h vs. <4.5 h) (n=657). CT perfusion-guided intravenous thrombolysis with alteplase (>4.5 h from last-seen-normal, wake-up stroke, or unknown onset) vs. Standard of care intravenous thrombolysis (<4.5 h from onset) was evaluated on Good functional outcome (modified Rankin Scale < 2) at 90 days (p=0.107). CT perfusion-guided intravenous thrombolysis beyond 4.5 hours achieved similar 90-day good functional outcomes (72% vs 60.4%, p=0.107) and symptomatic ICH rates (3.8% vs 3.8%, p=1) as standard <4.5h care.
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