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Liu H, Hu W, Zhang F, Gu W, Hong J, Chen J, Huang Y, Pan H. Efficacy and safety of rt-PA intravenous thrombolysis in patients with wake-up stroke: A meta-analysis. Medicine (Baltimore) 2022; 101:e28914. [PMID: 35363213 PMCID: PMC9282081 DOI: 10.1097/md.0000000000028914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/04/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND : Recombinant tissue plasminogen activator (rt-PA) is one of the most effective therapies for patients with acute ischemic stroke. However, wake-up stroke (WUS) is typically excluded from intravenous thrombolytic therapy because of the unclear time of symptom onset. Therefore, we aimed to assess the efficacy and safety of rt-PA intravenous thrombolysis in patients with WUS by meta-analysis. METHODS : We completed a systematic literature search of PubMed, Embase, the Cochrane Library, and SinoMed and included relevant studies of WUS patients covering rt-PA thrombolysis and nonthrombolysis (published from January 1, 2000, to February 28, 2021, with no language restrictions). The primary outcomes included safety outcomes and functional outcomes. Safety outcomes were measured according to the incidence of symptomatic intracranial hemorrhage and mortality within 90 days. The efficacy outcomes were measured based on 90-day modified Rankin Scale scores. We assessed pooled data using either a random-effects model (when P < .10, I2 > 50%) or a fixed-effects model (when P > .10, I2 < 50%). RESULTS : A total of 913 patients from 9 studies were included in the meta-analysis. All patients had ischemic stroke confirmed by computed tomography or magnetic resonance imaging. The incidence of modified Rankin Scale 0 to 2 was significantly higher in the rt-PA thrombolysis group compared with the nonthrombolysis group. And rt-PA thrombolytic WUS patients did not differ significantly from nonthrombolytic WUS patients in terms of 90-day mortality. However, the incidence of Symptomatic intracranial hemorrhage was also significantly higher in the rt-PA thrombolysis group than that in the nonthrombolysis group. CONCLUSIONS : Patients with WUS who received rt-PA thrombolysis had a significant positive effect within 90 days. In addition, although there was no significant increase in mortality, we need to be aware of the risk of intracranial hemorrhage transformation associated with rt-PA thrombolysis despite no obvious increase in mortality. The safety of rt-PA intravenous thrombolysis should be closely monitored in patients with WUS.
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Affiliation(s)
- Hongfa Liu
- The First Clinical College of Gannan Medical University, Ganzhou, Jiangxi, China
- Department of Geriatrics, The Third People's Hospital of Ganzhou, Ganzhou, Jiangxi, China
| | - Weihua Hu
- Department of Neurology, Ganxian People's Hospital, Ganzhou, Jiangxi, China
| | - Fang Zhang
- The First Clinical College of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Wei Gu
- The First Clinical College of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Jiankun Hong
- The First Clinical College of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Jianping Chen
- Department of General Practice, Ganzhou People's Hospital, Ganzhou, Jiangxi, China
| | - Ying Huang
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, Jiangxi, China
- Department of Neurology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Gannan Branch Center of National Geriatric Disease Clinical Medical Research Center, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Huoying Pan
- Department of Neurology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
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Fawaz AM, Wu S, Viswanathan D, Kaur K, Nuoman R, Nuoaman H, Adnan YA, Gandhi CD, Kurian C, Sahni R. Time to Wake-Up: Extending the Window for Management of Unknown-Onset Strokes. Cardiol Rev 2021; 29:26-32. [PMID: 32769626 DOI: 10.1097/crd.0000000000000336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The term "Wake-Up Stroke" is applied to a patient who displays no symptoms before sleep, but wakes with neurologic deficits suggestive of stroke. The current guidelines for acute ischemic stroke limit intravenous tissue plasminogen activator use to stroke patients in whom symptom onset or last known well is less than 4.5 hours. Approximately one-third of acute ischemic stroke patients present with unknown time of symptom onset and are often not eligible for intravenous reperfusion therapy in clinical practice. This review provides an overview of several earlier trials that used advanced neuroimaging to determine eligibility for reperfusion therapy in patients with unknown stroke onset. The reassuring results of these earlier trials that led to recent thrombolysis trials specifically targeted at "wake-up stroke" patients are discussed in this review. Ongoing studies aim to expand our knowledge regarding the safety and efficacy of thrombolysis in these patients.
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Affiliation(s)
- Al-Mufti Fawaz
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Sarah Wu
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Divya Viswanathan
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Kavneet Kaur
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children's Hospital-Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Halla Nuoaman
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Yasir Ammar Adnan
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Chirag D Gandhi
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Christeena Kurian
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Ramandeep Sahni
- From the Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY
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Wang C, Wang W, Ji J, Wang J, Zhang R, Wang Y. Safety of intravenous thrombolysis in stroke of unknown time of onset: A systematic review and meta-analysis. J Thromb Thrombolysis 2021; 52:1173-1181. [PMID: 33963484 DOI: 10.1007/s11239-021-02476-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
The safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke of unknown time of onset (SUTO) was unclear and mostly concerned. We sought to investigate the safety in terms of symptomatic intracranial hemorrhage (sICH) and death in SUTO patients treated with IV-tPA. We searched PubMed and EMBASE from inception to 2 December 2020 for eligible studies reporting IV-tPA in SUTO patients compared to conservative medical therapy, or to stroke of known onset time (SKOT) treated with IV-tPA within standard time window. We pooled relative risk (RR) with 95% confidence interval (95%CI) with random-effects model. Twenty-four studies were included, enrolling 77,398 patients. SUTO patients with IV-tPA had higher incidence of sICH than that in SUTO patients without IV-tPA (3.8% versus 0.96%; RR = 3.75, 95%CI: 2.69-5.22) but comparable to that in SKOT patients with IV-tPA (3.8% versus 4.1%; RR = 1.16, 95%CI: 0.94-1.44). There was no significant difference in death risk in SUTO patients with IV-tPA versus SUTO patients without IV-tPA (RR = 1.34, 95%CI: 0.60-3.01) and versus SKOT patients with IV-tPA (RR = 1.19, 95%CI: 0.95-1.50). Compared with SUTO patients without IV-tPA, SUTO patients with IV-tPA had higher likelihood of favorable functional outcome (adjusted RR = 1.28, 95%CI: 1.03-1.60) and functional independence (adjusted RR = 1.95, 95%CI: 1.24-3.06), comparable to that in SKOT patients with IV-tPA in favorable functional outcome (adjusted RR = 0.67, 95%CI: 0.38-1.20) and functional independence (adjusted RR = 0.84, 95%CI: 0.59-1.18). SUTO patients could be treated safely and effectively with IV-tPA under the guidance of imaging evaluation.
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Affiliation(s)
- Chen Wang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University. Address, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China.,Dalian Medical University, Address: 9 Western Sections, Lvshun South Street, Lvshunkou District, Dalian, 116044, People's Republic of China
| | - Wanting Wang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University. Address, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China.,Dalian Medical University, Address: 9 Western Sections, Lvshun South Street, Lvshunkou District, Dalian, 116044, People's Republic of China
| | - Jianling Ji
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University. Address, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China.,Dalian Medical University, Address: 9 Western Sections, Lvshun South Street, Lvshunkou District, Dalian, 116044, People's Republic of China
| | - Jian Wang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University. Address, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Ruijun Zhang
- The First Hospital of China Medical University. Address, 155 Nanjingbei Street, Heping District, Shenyang, 110001, People's Republic of China
| | - Yujie Wang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University. Address, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China.
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Evans JW, Graham BR, Pordeli P, Al-Ajlan FS, Willinsky R, Montanera WJ, Rempel JL, Shuaib A, Brennan P, Williams D, Roy D, Poppe AY, Jovin TG, Devlin T, Baxter BW, Krings T, Silver FL, Frei DF, Fanale C, Tampieri D, Teitelbaum J, Iancu D, Shankar J, Barber PA, Demchuk AM, Goyal M, Hill MD, Menon BK. Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial. AJNR Am J Neuroradiol 2017; 39:102-106. [PMID: 29191873 DOI: 10.3174/ajnr.a5462] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/15/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.
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Affiliation(s)
- J W Evans
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - B R Graham
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - P Pordeli
- Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - F S Al-Ajlan
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.)
| | - R Willinsky
- Department of Medical Imaging (R.W., W.J.M.)
| | | | | | - A Shuaib
- Medicine (Neurology) (A.S.), University of Alberta, Edmonton, Alberta, Canada
| | - P Brennan
- Departments of Neuroradiology (P.B.)
| | - D Williams
- Geriatric and Stroke Medicine (D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - D Roy
- Departments of Radiology (D.R.)
| | - A Y Poppe
- Neurosciences (A.Y.P.), Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - T G Jovin
- Department of Neurology (T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - B W Baxter
- Department of Radiology (B.W.B), Erlanger Hospital, University of Tennessee, Chattanooga, Tennessee
| | | | - F L Silver
- Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - D F Frei
- Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado
| | - C Fanale
- Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada
| | - D Tampieri
- Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado
| | - J Teitelbaum
- Montreal Neurological Institute (J.T.), McGill University, Montreal, Quebec, Canada
| | - D Iancu
- Department of Radiology (D.I.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J Shankar
- Department of Neuroradiology (J.S.), Dalhousie University, Halifax, Nova Scotia, Canada
| | - P A Barber
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - M D Hill
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).,Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - B K Menon
- From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.) .,Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada.,Foothills Medical Centre (B.K.M.), Calgary, Alberta, Canada
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