This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
Abstract
Objective To investigate differences in procedure times, safety, and efficacy outcomes comparing 2 different protocols to enable thrombolysis in the extended or unknown time window after stroke onset with either multimodal CT or MRI.
Methods Patients with ischemic stroke in the extended or unknown time window who received IV thrombolysis between January 2011 and May 2019 were identified from an institutional registry. Imaging-based selection was done by multimodal CT or MRI according to institutional treatment algorithms.
Results IV thrombolysis was performed in 100 patients (54.3%) based on multimodal CT imaging and in 84 patients (45.7%) based on MRI. Baseline clinical data, including stroke severity and time from last seen normal to hospital admission, were similar in patients with CT and MRI. Door-to-needle times were shorter in patients with CT-based selection (median [interquartile range] 45 [37–62] minutes vs 75 [59–90] minutes; mean difference [95% confidence interval (CI)] −28 minutes [−35 to −21]). No differences were detected regarding the incidence of symptomatic intracranial hemorrhage (2 [2.0%] vs 4 [4.8%]; adjusted odds ratio [aOR] [95% CI] 0.47 [0.08–2.83]) and favorable outcome at day 90 (25 [33.8%] vs 33 [42.9%]; aOR 0.95 [0.45–2.02]).
Conclusion IV thrombolysis in ischemic stroke in the unknown or extended time window appeared safe in CT- and MRI-selected patients, while the use of CT imaging led to faster door-to-needle times.
Classification of evidence This study provides Class IV evidence that for patients with ischemic stroke in the extended or unknown time window, imaging-based selection for IV thrombolysis by multimodal CT compared to MRI led to shorter door-to-needle times.
Glossary
- aβ=
- adjusted β coefficient;
- aOR=
- adjusted odds ratio;
- CI=
- confidence interval;
- CTP=
- CT perfusion;
- DEFUSE=
- Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution;
- DWI=
- diffusion-weighted imaging;
- ECASS=
- European Cooperative Acute Stroke Study;
- EPITHET=
- Echoplanar Imaging Thrombolytic Evaluation Trial;
- EXTEND=
- Extending the Time for Thrombolysis in Emergency Neurologic Deficits;
- FLAIR=
- fluid-attenuated inversion recovery;
- ICH=
- intracranial hemorrhage;
- MD=
- mean difference;
- MR=
- magnetic resonance;
- mRS=
- modified Rankin Scale;
- NIHSS=
- NIH Stroke Scale;
- RD=
- risk difference;
- rtPA=
- recombinant tissue plasminogen activator;
- SITS-MOST=
- Safe Implementation of Thrombolysis in Stroke-Monitoring Study;
- WAKE-UP=
- Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
↵* These authors contributed equally to this work.
Editorial, page 989
Class of Evidence: NPub.org/coe
- Received March 4, 2020.
- Accepted in final form August 3, 2020.
- © 2020 American Academy of Neurology
AAN Members
We have changed the login procedure to improve access between AAN.com and the Neurology journals. If you are experiencing issues, please log out of AAN.com and clear history and cookies. (For instructions by browser, please click the instruction pages below). After clearing, choose preferred Journal and select login for AAN Members. You will be redirected to a login page where you can log in with your AAN ID number and password. When you are returned to the Journal, your name should appear at the top right of the page.
AAN Non-Member Subscribers
Purchase access
Letters: Rapid online correspondence
- Author response: Multimodal CT or MRI for IV-Thrombolysis in ischemic stroke with unknown time of onset
- Reader response: Multimodal CT or MRI for IV thrombolysis in ischemic stroke with unknown time of onset
REQUIREMENTS
You must ensure that your Disclosures have been updated within the previous six months. Please go to our Submission Site to add or update your Disclosure information.
Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment.
If you are responding to a comment that was written about an article you originally authored:
You (and co-authors) do not need to fill out forms or check disclosures as author forms are still valid
and apply to letter.
Submission specifications:
- Submissions must be < 200 words with < 5 references. Reference 1 must be the article on which you are commenting.
- Submissions should not have more than 5 authors. (Exception: original author replies can include all original authors of the article)
- Submit only on articles published within 6 months of issue date.
- Do not be redundant. Read any comments already posted on the article prior to submission.
- Submitted comments are subject to editing and editor review prior to posting.
You May Also be Interested in
Alert Me
Recommended articles
Thrombolysis for acute ischemic stroke in the unwitnessed or extended therapeutic time window
Multimodal imaging selection for IV alteplase in unknown time of onset stroke
Reader Response: Multimodal CT or MRI for IV Thrombolysis in Ischemic Stroke With Unknown Time of Onset
Low-Dose vs Standard-Dose Alteplase in Acute Lacunar Ischemic Stroke