IV thrombolysis for treatment of patients with stroke upon awakening: Yes? No?

Intravenous thrombolysis in wake-up stroke: real-world data from the Austrian Stroke Unit Registry

BACKGROUND AND PURPOSE

Data on real-world experience with intravenous thrombolysis (IV tPA) in wake-up stroke (WUS) are limited. The aim of this study was to examine the efficacy and safety of IV tPA in patients with WUS included in the Austrian Stroke Unit Registry.

METHODS

Data from a large nationwide stroke unit registry including initial stroke severity, vascular risk factors, comorbidities, treatment with IV tPA, symptomatic intracerebral haemorrhage (sICH) and functional outcome were extracted and analysed. Patients with WUS were compared with patients with known-onset stroke (KOS) regarding the frequency of IV tPA treatment, neurological improvement (National Institutes of Health Stroke Scale score ≥4), sICH and 3-month functional outcome by modified Rankin Scale score using standard statistical tests.

RESULTS

A total of 107 895 stroke patients entered the analysis, including 12 534 with WUS and 91 899 with KOS. Altogether, 904 (7.2%) patients with WUS received IV tPA as compared with 16 694 (18.2%) patients with KOS. Patients with WUS who received IV tPA treatment had twofold higher initial National Institutes of Health Stroke Scale score (median 8 vs. median 4) as compared with patients with KOS. There was no statistical difference in functional outcome by modified Rankin Scale score 0-1 at 3 months between patients with WUS and patients with KOS treated with IV tPA (adjusted odds ratio, 1.08; 95% confidence interval, 0.9-1.31). Also, the rate of sICH did not differ (4.1% vs. 4%, P = 0.852).

CONCLUSIONS

In this large non-randomized comparison, the safety and efficacy of IV tPA in patients with WUS in the real-world setting seems to be comparable to patients with KOS.

Tissue plasminogen activator; identifying major barriers related to intravenous injection in ischemic acute cerebral infraction

BACKGROUND

According to previous publications, in patients with acute ischemic cerebral infarction, thrombolytic therapy using intravenous tissue plasminogen activator (IV-tPA) necessitates precise documentation of symptoms' onset. The aim of this study was to identify major barriers related to the IV-tPA injection in such patients.

MATERIALS AND METHODS

Between the year 2014-2015, patients with definitive diagnosis of acute cerebral infarction (n = 180) who attended the neurology ward located at the Isfahan Alzahra Hospital were studied. To investigate barriers related to door to IV-tPA needle time, personal reasons, and criteria for inclusion or exclusion of patients, three questionnaire forms were designed based on the Food and Drug Administration-approved indications or contraindications.

RESULTS

The mean age of males versus females was 60 versus 77.5 years (ranged 23-93 vs. 29-70 years), respectively. Out of total population, only 10.7% transferred to hospital in <4.5 h after the onset of symptoms. Regarding to eligibility for IV-tPA, 68.9% of total population have had criteria for such treatment. Concerning to both items such as transferring to hospital in <4.5 h after the onset of symptoms and eligibility for IV-tPA, only 6.6% of total population met the criteria for such management. There was ignorance or inattention to symptoms in 75% of population studied. There was a mean of 195.92 ± 6.65 min (182.8-209.04 min) for door to IV-tPA needle time.

CONCLUSION

Despite the international guidelines for IV-tPA injection within 3-4.5 h of ischemic stroke symptoms' onset, the results of this study revealed that falling time due to ignorance of symptoms, literacy, and living alone might need further attention. As a result, to decrease death and disability, educational programs related to the symptoms' onset by consultant neurologist in Isfahan/Iran seem to be advantageous.