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

Neurology. 2020 Dec 1;95(22):e2954-e2964. doi: 10.1212/WNL.0000000000011059. Epub 2020 Oct 21.

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.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Female
  • Fibrinolytic Agents / administration & dosage*
  • Humans
  • Incidence
  • Intracranial Hemorrhages* / diagnostic imaging
  • Intracranial Hemorrhages* / drug therapy
  • Intracranial Hemorrhages* / epidemiology
  • Ischemic Stroke* / diagnostic imaging
  • Ischemic Stroke* / drug therapy
  • Ischemic Stroke* / epidemiology
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Multimodal Imaging / statistics & numerical data*
  • Process Assessment, Health Care / statistics & numerical data*
  • Registries / statistics & numerical data*
  • Retrospective Studies
  • Thrombolytic Therapy / statistics & numerical data*
  • Time Factors
  • Time-to-Treatment / statistics & numerical data*
  • Tomography, X-Ray Computed

Substances

  • Fibrinolytic Agents