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

• Published in: European journal of neurology Vol. 27; no. 1; pp. 168 - 174
• Main Authors: Feil, K., Reidler, P., Kunz, W. G., Küpper, C., Heinrich, J., Laub, C., Müller, K., Vöglein, J., Liebig, T., Dieterich, M., Kellert, L.
• Format: Journal Article
• Language: English
• Published: England John Wiley & Sons, Inc 01-01-2020
• Subjects: Administration, Intravenous; Aged; Aged, 80 and over; Blood flow; Blood volume; Brain Infarction - diagnostic imaging; Cerebral blood flow; Cerebrovascular Circulation; Clinical trials; Computed tomography; computed tomography perfusion imaging; Decision making; extended time window; Female; Fibrinolytic Agents - administration & dosage; Fibrinolytic Agents - therapeutic use; Hemorrhage; Humans; Intracranial Hemorrhages - diagnostic imaging; Intravenous administration; intravenous thrombolysis; Ischemia; Magnetic Resonance Imaging; Male; Medical imaging; Middle Aged; Patients; Perfusion; Perfusion Imaging; Safety; Stroke; Stroke - diagnostic imaging; Stroke - surgery; Stroke - therapy; Thrombectomy - methods; Thrombolysis; Time-to-Treatment; Tomography; Tomography, X-Ray Computed; Treatment Outcome; wake‐up stroke; Windows (intervals); computed tomography perfusion imaging; intravenous thrombolysis; wake-up stroke; stroke; extended time window
• ISSN: 1351-5101; 1468-1331
• DOI: 10.1111/ene.14051

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.