MRI-based intravenous thrombolysis in stroke patients with unknown time of symptom onset

• Published in: European journal of neurology Vol. 19; no. 2; pp. 348 - 350
• Main Authors: Ebinger, M., Scheitz, J. F., Kufner, A., Endres, M., Fiebach, J. B., Nolte, C. H.
• Format: Journal Article
• Language: English
• Published: Oxford, UK Blackwell Publishing Ltd 01.02.2012; John Wiley & Sons, Inc
• Subjects: Age; Aged; Aged, 80 and over; Brain Ischemia - drug therapy; Clinical trials; Data processing; Female; Fibrillation; Fibrinolytic Agents - adverse effects; Fibrinolytic Agents - therapeutic use; Hemorrhage; Humans; Intravenous administration; Magnetic Resonance Imaging; Male; Medical research; Mortality; MRI; Multivariate analysis; Off-Label Use; Stroke; Stroke - drug therapy; t-Plasminogen activator; thrombolysis; Thrombolytic Therapy - adverse effects; Thrombolytic Therapy - methods; Time Factors; Tissue Plasminogen Activator - adverse effects; Tissue Plasminogen Activator - therapeutic use; Treatment Outcome; unknown time of symptom onset
• ISSN: 1351-5101; 1468-1331
• DOI: 10.1111/j.1468-1331.2011.03504.x

Background:  Currently, stroke patients with unknown time of symptom onset (UTOS) are excluded from therapy with intravenous tissue Plasminogen Activator. We hypothesized that MRI‐based intravenous thrombolysis is safe in UTOS. Methods:  We analyzed radiological and clinical data as well as outcomes of stroke patients (including UTOS) who received intravenous thrombolytic therapy after MRI. Results:  Compared to patients with known time of symptom onset (n = 131), UTOS (n = 17) were older (81, 71–88 vs. 75 years, 66–82, P = 0.03), had a longer median time between last‐seen‐well and thrombolysis (12.3 h, IQR 11.5–15.2 h vs. 2.1 h, 1.8–2.8 h, P < 0.01), had a longer median door‐to‐needle time (86 min, 49–112 vs. 60 min, 49–76, P = 0.02), and a higher rate of arterial obstruction on MR‐angiography (82.4% vs. 56.5%, P = 0.04). No symptomatic intracerebral hemorrhage occurred in UTOS. After 3 months, there was no significant difference between groups concerning good functional outcome (modified Rankin Scale 0–2; 35.3% vs. 49.6%, P = 0.26) or mortality (0% vs. 15.3%, P = 0.08). In multivariate analyses including age, gender, baseline NIHSS, and atrial fibrillation UTOS did not have an independent effect on good functional outcome after 3 months (OR 1.16; 0.32–4.12, P = 0.81). Conclusions:  Thrombolysis after MRI seems safe and effective in UTOS. This observation may encourage those who plan prospective placebo‐controlled trials of thrombolytics in this subgroup of stroke patients.