Intravenous thrombolytic therapy with alteplase under the guidance of MRI in patients with wake-up ischemic stroke

Abstract

Objective To investigate the safety, effectiveness, and outcome influencing factors of alteplase intravenous thrombolytic therapy in patients with wake-up ischemic stroke (WUIS) under the guidance of MRI. Methods From May 2016 to June 2018, patients with WUIS admitted to the Department of Neurology and Emergency Center of Dongping County People's Hospital were enrolled retrospectively. Patients with WUIS were examined with emergency craniocerebral MRI. Patients with diffusion-weighted imaging and fluid attenuated inversion recovery sequence (DWI/FLAIR) mismatch were treated with alteplase intravenous thrombolysis, and the DWI/FLAIR match patients were not treated with it. The changes of the NIHSS scores at 24 h after admission compared with baseline and the modified Rankin Scale (mRS) score at 90 d were used to analyze the efficacy of treatment. The incidence of complications of intracerebral hemorrhage within 24 h after admission was used to analyze the safety of treatment. Results A total of 65 patients with WUIS were enrolled. Among them, DWI/FLAIR of 30 patients did not match, and DWI/FLAIR of 35 matched. There was no significant difference in demographic and baseline clinical data between the 2 groups. Compared with the baseline, the NIHSS score was significantly improved at 24 h after admission in the DWI/FLAIR mismatch group (P<0.05), whereas the DWI/FLAIR match group was not. The NIHSS score of the DWI/FLAIR mismatch group at 24 h was significantly lower than that of the DWI/FLAIR match group (6.35±2.56 vs. 9.69±3.04; t=4.702, P=0.001), and the good outcome rate at 90 d (mRS score 0-2) was significantly higher than the DWI/FLAIR match group (66.7% vs. 22.7%; χ2=5.634, P=0.018). Multivariate logistic regression analysis showed that alteplase intravenous thrombolysis (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.11-1.43; P<0.001) was a good independent protective factor of the outcome, but hypertension (OR 0.87, 95% CI 0.81-0.92; P<0.001), diabetes (OR 0.61, 95% CI 0.52-0.72; P<0.001), and large-artery atherosclerosis (OR 0.74, 95% CI 0.67-0.82; P<0.001) were the independent risk factors for poor outcome. Two patients had intracerebral hemorrhage within 24 h after admission in the DWI/FLAIR mismatch group and the DWI/FLAIR match group did not have any intracerebral hemorrhage, but there was no significant difference between the 2 groups. Conclusion Intravenous thrombolysis with alteplase was safe and effective for DWI/FLAIR mismatch patients with WUIS. Key words: Stroke; Brain Ischemia; Thrombolytic Therapy; Tissue Plasminogen Activator; Magnetic Resonance Imaging; Treatment Outcome; Cerebral Hemorrhage; Time Factor