Multimodal CT or MRI for IV thrombolysis in ischemic stroke with unknown time of onset

Abstract

ObjectiveTo 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 using either multimodal CT or MRI.MethodsPatients 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.ResultsIV-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 CT- and MRI-patients. Door-to-needle times were shorter in patients with CT-based selection (median [IQR] 45 minutes [37–62] vs 75 minutes [59–90]; mean difference [95% CI] −28 minutes [−35 to −21]). No differences were detected regarding the incidence of symptomatic intracranial hemorrhage (2 [2.0%] vs 4 [4.8%]; 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).ConclusionIV-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 evidenceThis 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.

Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

“…04:00 if the patient fell for sleep at midnight and woke up with symptoms at 08:00) is considered the starting point; IVT can be performed in patients with favorable penumbral imaging up to 9 h after (in this example up to 13:00). The Erlangen study criteria 29 of MQ > 1.4 may be safe in patients with ischemic core <5 ml after 9 h from LSW as off-label IVT treatment (Exp Op). EVT is unavailable in this scenario.…”

“…lacunar stroke <4.5 h from awakening). The Erlangen study criteria 29 of MQ > 1.4 may be safe in patients with ischemic core <5 ml after 9 h from LSW as off-label IVT treatment (Exp Op). EVT is unavailable in this scenario.…”

“…If DEFUSE 3 or DAWN study criteria are fulfilled, EVT is strongly recommended up to 24 h from LSW. The Erlangen study criteria 29 of MQ > 1.4 may allow safe IVT in patients with ischemic core <5 ml after 9 h from LSW as off-label IVT treatment. Bridging therapy using the EXTEND criteria have not been tested during the trial but may be considered only when recanalization is predicted to occur in >2 h for AIS patients with favorable IVT risk–benefit profile, notably extremely limited or no ischemic core (expert opinion).…”

“…IVT after 9 h may be offered if MQ exceeds 1.4, according to the Erlangen study. 29 MR perfusion is the optimal imaging modality for WUS, when available; IVT with alteplase in WUS may be performed either by using perfusion criteria as described in the EXTEND trial or the WAKE-UP DWI/FLAIR dissociation criteria (expert opinion). If DEFUSE 3 or DAWN study criteria are fulfilled, EVT is strongly recommended up to 16 h and 24 h, respectively from LSW.…”

“…A most recent single-center retrospective study took a step further in establishing the role of IVT in unknown time of symptom onset or extended time windows using advanced neuroimaging. Macha et al 29 in Erlangen, Germany, performed IVT in 184 patients with evidence of salvageable brain tissue at risk on CT or MR perfusion imaging (mismatch between hypoperfusion versus infarcted core, mismatch quotient > 1.4). Patients had either unknown or >4.5 h duration of symptoms, without upper time limit; 36% of patients received EVT in addition to systemic thrombolysis.…”