Abstract
Advanced neuroimaging is one of the most important means that we have in the attempt to overcome time constraints and expand the use of intravenous thrombolysis (IVT). We assessed whether, and how, the prior use of advanced neuroimaging (AN), and more specifically CT/MR perfusion post-processed with RAPID software, regardless of time from symptoms onset, affected the outcomes of acute ischemic stroke (AIS) patients who received IVT. Methods. We retrospectively evaluated consecutive AIS patients who received intravenous thrombolysis monotherapy (without endovascular reperfusion) during a six-year period. The study population was divided into two groups according to the neuroimaging protocol used prior to IVT administration in AIS patients (AN+ vs. AN−). Safety outcomes included any intracranial hemorrhage (ICH) and 3-month mortality. Effectiveness outcomes included door-to-needle time, neurological status (NIHSS-score) on discharge, and functional status at three months assessed by the modified Rankin Scale (mRS). Results. The rate of IVT monotherapy increased from ten patients per year (n = 29) in the AN− to fifteen patients per year (n = 47) in the AN+ group. Although the onset-to-treatment time was longer in the AN+ cohort, the two groups did not differ in door-to-needle time, discharge NIHSS-score, symptomatic ICH, any ICH, 3-month favorable functional outcome (mRS-scores of 0–1), 3-month functional independence (mRS-scores of 0–2), distribution of 3-month mRS-scores, or 3-month mortality. Conclusion. Our pilot observational study showed that the incorporation of advanced neuroimaging in the acute stroke chain pathway in AIS patients increases the yield of IVT administration without affecting the effectiveness and safety of the treatment.
Highlights
Intravenous thrombolysis (IVT) with alteplase in acute ischemic stroke (AIS) administered within the first 4.5 hours following symptom onset remains the mainstay of acute reperfusion therapies [1,2,3]
We retrospectively evaluated consecutive AIS patients who received IVT admitted to our European Stroke Organization certified stroke unit
Patients were included if they fulfilled the following criteria: (1) aged over 18 years old; (2) clinically diagnosed with AIS with a measurable neurologic deficit on the National Institute of Health Stroke Scale (NIHSS) presenting within the 4.5 h window from symptom onset; (3) AIS patients were considered eligible for the extended time window of 4.5–9 h if they presented after 4.5 h and sooner than 9 h from last-seen-well, according to the clinical and neuroimaging inclusion criteria of the EXTEND trial [10]; (4) AIS patients who woke up with symptoms of stroke («wake-up stroke») were treated according to the WAKE-UP trial [18] protocol; and (5) AIS patients treated with IVT monotherapy
Summary
Intravenous thrombolysis (IVT) with alteplase in acute ischemic stroke (AIS) administered within the first 4.5 hours following symptom onset remains the mainstay of acute reperfusion therapies [1,2,3]. Strict inclusion and exclusion criteria of the pivotal randomized controlled clinical trials (RCTs), as well as health care system disparities, such as public awareness on how to act in case of stroke symptoms, organization of emergency medical services, and the paucity of organized stroke centers in rural areas [6], have been significant barriers to overcome. Off-label use of IVT [7,8] is increasingly incorporated in the everyday clinical practice of many stroke practitioners. Advanced neuroimaging may help us overcome time constraints and expand the implementation of acute reperfusion therapies [9]. Numerous stroke centers and stroke units worldwide have incorporated the use of CT and MR perfusion in their acute therapeutic pathways
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