Department of Neurology, Ludwig Maximilian University, Munich, Germany.
German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany.
Eur J Neurol. 2020 Jan;27(1):168-174. doi: 10.1111/ene.14051. Epub 2019 Aug 21.
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.
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).
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.
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.
静脉溶栓（IVT）治疗急性缺血性脑卒中的时间窗限制在已知或假定发病后 4.5 小时内。最近，磁共振成像引导的觉醒性脑卒中（WUS）治疗决策显示是有效的。本研究的目的是确定通过计算机断层灌注（CTP）成像选择的超过 4.5 小时时间窗的患者接受 IVT 的安全性和结果。
我们分析了 2015 年 1 月至 2018 年 10 月期间所有根据 CTP 接受 IVT 治疗且最后一次见到清醒状态的时间超过 4.5 小时的连续患者。通过评估脑血流和脑血容量图之间的不匹配来对 CTP 进行视觉评估。根据 Alberta 卒中项目早期 CT 评分（ASPECTS）记录早期梗死征象。安全性数据包括死亡率和症状性颅内出血（sICH）。通过改良 Rankin 量表（mRS）评估随访情况。
共有 70 名患者符合纳入标准（平均年龄±标准差为 77.6±11.5 岁，50.0%为女性）。入院时美国国立卫生研究院卒中量表（NIHSS）评分中位数为 8.0 [四分位距（IQR），4-14]。延长时间窗的最常见原因是 WUS（60.0%）和延迟入院（27.1%）。从最后一次见到清醒到 IVT 的中位时间为 11.4 小时。ASPECTS 中位数为 10（IQR，9-10），CTP 不匹配率为 90%（IQR，80%-100%）。共有 24 名患者（34.3%）接受了额外的机械取栓术。4 名患者（5.7%）发生 sICH。随访时，49.3%的患者 mRS 评分为 0-2，22.4%的患者 mRS 评分为 0-1。
对于超过 4.5 小时的延长时间窗患者，基于 CTP 决策的 IVT 治疗可能是一种安全的治疗方法。需要在临床试验中进一步评估。
