PD Dr. Georg Kägi
Dr. Jochen Vehoff
Background The WAKE-UP trial showed a favourable outcome of intravenous thrombolysis with alteplase (iv-tPA) in patients with unknown onset of stroke, selected by DWI/FLAIR mismatch on MRI. In many centres, however, acute stroke patients are evaluated by CT-based imaging methods. We aimed at evaluating the outcome and safety of a multimodal CT-based decision making algorithm for iv-tPA in acute stroke patients with unknown symptom onset. Methods Retrospective, single centre analysis. Data from iv-tPA treated patients with unknown symptom onset and from those with a defined symptom onset <4.5 hours were retrieved from the Swiss Stroke Registry (SSR) from July 2014 until May 2018. Patients with endovascular treatment were excluded. Results A mRS score of 0-1 after 90 days was observed in 16/28 patients with unknown symptom onset (57%). The rate of favourable outcome was comparable to patients treated within 4.5 hours after symptom onset (134/272; (49%) p=0.427). There was no difference between the two groups regarding the rates of sICH according to ECASS definition (0/28 vs. 7/272, p=0.395) and death after 3 months (1/28 vs 23/272, p=0.252). Conclusions CT-based selection of patients with unknown symptom onset for iv-tPA is feasible and seems to provide comparable efficacy and safety as in patients treated within the standard time window for iv-tPA of <4.5 hours after symptom onset. Meanwhile the results from the recently finished Extend Australia Study showed a benefit for iv-tPA in patients with wake-up stroke, selected by CT perfusion, compared to placebo.
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