Addressing a real-life problem: treatment with intravenous thrombolysis and mechanical thrombectomy in acute stroke patients with an extended time window beyond 4.5 h based on computed tomography perfusion imaging

K Feil; P Reidler; W G Kunz; C Küpper; J Heinrich; C Laub; K Müller; J Vöglein; T Liebig; M Dieterich; L Kellert

doi:10.1111/ene.14051

Addressing a real-life problem: treatment with intravenous thrombolysis and mechanical thrombectomy in acute stroke patients with an extended time window beyond 4.5 h based on computed tomography perfusion imaging

Eur J Neurol. 2020 Jan;27(1):168-174. doi: 10.1111/ene.14051. Epub 2019 Aug 21.

Authors

K Feil^{1

2}, P Reidler³, W G Kunz³, C Küpper¹, J Heinrich¹, C Laub¹, K Müller¹, J Vöglein^{1

4}, T Liebig⁵, M Dieterich^{1

2

6}, L Kellert¹

Affiliations

¹ Department of Neurology, Ludwig Maximilian University, Munich, Germany.
² German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany.
³ Department of Radiology, Ludwig Maximilian University, Munich, Germany.
⁴ German Center for Neurodegenerative Diseases, Munich, Germany.
⁵ Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany.
⁶ Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.

PMID: 31349393
DOI: 10.1111/ene.14051

Abstract

Background and purpose: Acute ischemic stroke treatment with intravenous thrombolysis (IVT) is restricted to a time window of 4.5 h after known or presumed onset. Recently, magnetic resonance imaging-guided treatment decision-making in wake-up stroke (WUS) was shown to be effective. The aim of this study was to determine the safety and outcome of IVT in patients with a time window beyond 4.5 h selected by computed tomography perfusion (CTP) imaging.

Methods: We analyzed all consecutive patients last seen well beyond 4.5 h after stroke onset treated with IVT based on CTP between January 2015 and October 2018. CTP was visually assessed to estimate the mismatch between cerebral blood flow and cerebral blood volume maps. Early infarct signs were documented according to Alberta Stroke Program Early CT Score (ASPECTS). Safety data were obtained for mortality and symptomatic intracerebral hemorrhage (sICH). Follow-up was assessed with the modified Rankin Scale (mRS).

Results: A total of 70 patients fulfilled the inclusion criteria (mean age ± SD 77.6 ± 11.5 years, 50.0% female). Median National Institutes of Health Stroke Scale score on admission was 8.0 [interquartile range (IQR), 4-14]. The most frequent reasons for an extended time window were WUS (60.0%) and delayed hospital admission (27.1%). Median time from last seen well to IVT was 11.4 h. Median ASPECTS was 10 (IQR, 9-10) and CTP mismatch 90% (IQR, 80%-100%). A total of 24 patients (34.3%) underwent additional mechanical thrombectomy. sICH occurred in four patients (5.7%). At follow-up, 49.3% had an mRS score of 0-2 and 22.4% had an mRS score of 0-1.

Conclusions: In patients presenting in an extended time window beyond 4.5 h, IVT treatment with decision-making based on CTP might be a safe procedure. Further evaluation in clinical trials is needed.

Keywords: computed tomography perfusion imaging; extended time window; intravenous thrombolysis; stroke; wake-up stroke.

MeSH terms

Administration, Intravenous
Aged
Aged, 80 and over
Brain Infarction / diagnostic imaging
Cerebrovascular Circulation
Female
Fibrinolytic Agents / administration & dosage*
Fibrinolytic Agents / therapeutic use*
Humans
Intracranial Hemorrhages / diagnostic imaging
Magnetic Resonance Imaging
Male
Middle Aged
Perfusion Imaging
Stroke / diagnostic imaging*
Stroke / surgery
Stroke / therapy*
Thrombectomy / methods*
Time-to-Treatment
Tomography, X-Ray Computed
Treatment Outcome

Substances

Fibrinolytic Agents