Abstract
Background: rt-PA for ischemic stroke in the unknown or extended time window beyond the first 4. 5 h after symptom onset is safe and effective for certain patients after selection by multimodal neuroimaging. However, the evidence for this approach comes mainly from patients with anterior circulation stroke (ACS), while the data on posterior circulation stroke (PCS) are scarce.Methods: Ischemic stroke patients treated with IV-thrombolysis in the unknown or extended time window between January 2011 and May 2019 were identified from an institutional registry. The patients were categorized into PCS or ACS based on clinico-radiological findings. We analyzed the hemorrhagic complications, clinical and imaging efficacy outcomes, and mortality rates by comparing the PCS and ACS patient groups. Adjusted outcome analyses were performed after propensity score matching for the relevant factors.Results: Of the 182 patients included, 38 (20.9%) had PCS and 144 (79.1%) had ACS. Symptomatic acute large vessel occlusion (LVO) was present in 123 patients on admission [27 (22.0%) PCS and 96 (78.0%) ACS]. The score on the National Institutes of Health Stroke Scale (NIHSS), the time from last seen normal, and the door-to-needle times were similar in PCS and ACS. In patients with LVO, the NIHSS score was lower [8 (5–15) vs. 14 (9–18), p = 0.005], and infarction visible on follow-up imaging was less common [70.4 vs. 87.5%; aRD, −18.9% (−39.8 to −2.2%)] in the PCS patient group. There was a trend toward a lower risk for intracranial hemorrhage (ICH) following intravenous thrombolysis in PCS vs. ACS, without reaching a statistical significance [5.3 vs. 16.9%; aRD, −10.4% (−20.4 to 4.0%)]. The incidence of symptomatic ICH [according to the ECASS III criteria: 2.6 vs. 3.5%; aRD, −2.9% (−10.3 to 9.2%)], efficacy outcomes, and mortality rates were similar in PCS and ACS patients.Conclusions: In this real-world clinical cohort, the safety and the efficacy of rt-PA for ischemic stroke in the unknown or extended time window did not show relevant differences between PCS and ACS, with a trend toward less hemorrhagic complications in PCS. The findings reconfirm the clinician in the usage of rt-PA beyond the first 4.5 h also in selected patients with PCS.
Highlights
In up to 16% of acute ischemic strokes treated with IVthrombolysis, the territories of the posterior circulation, including the vertebral, basilar, or posterior cerebral arteries, are affected [1,2,3,4]
The patients were eligible for IV-thrombolysis using multimodal CT or MR imaging according to our institutional treatment algorithm for the management of ischemic stroke in the extended or unknown time window as described previously [16]
Patients with occlusion of the internal carotid and middle or anterior cerebral artery were categorized as anterior circulation stroke (ACS) patients, and patients with occlusion of the vertebral, basilar, or posterior cerebral artery were categorized as posterior circulation stroke (PCS) patients
Summary
In up to 16% of acute ischemic strokes treated with IVthrombolysis, the territories of the posterior circulation, including the vertebral, basilar, or posterior cerebral arteries, are affected [1,2,3,4]. IV-thrombolysis is the standard of care for acute ischemic stroke within 4.5 h from symptom onset irrespective of the vascular territory affected [6, 7]. Several studies could demonstrate the safety and the efficacy of IV-thrombolysis for selected patients in the unknown or extended time window beyond 4.5 h [8,9,10]. The proportion of PCS was low or not reported in most randomized rt-PA trials with treatment within 4.5 h from onset and with treatment in the unknown or extended time window [8, 9, 11,12,13,14]. The transfer of the results to patients with PCS might be inappropriate
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