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Tissue Window in Stroke Thrombolysis Study (TWIST): A Safety Study

Published online by Cambridge University Press:  23 September 2014

Michael D. Hill ,
Carol Kenney ,
Imanuel Dzialowski ,
Jean-Martin Boulanger ,
Andrew M. Demchuk ,
Philip A. Barber ,
Timothy W.J. Watson ,
Nicolas U. Weir ,
Alastair M. Buchan  and
Calgary Stroke Program
Michael D. Hill*
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Carol Kenney
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Imanuel Dzialowski
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Jean-Martin Boulanger
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Andrew M. Demchuk
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Philip A. Barber
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Timothy W.J. Watson
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Nicolas U. Weir
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Alastair M. Buchan
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
*
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Foothills Hospital, Rm 1242A, 1403 29th Street NW, Calgary, Alberta, T2N 2T9, Canada. email: [email protected]
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Abstract:

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Background:

Stroke thrombolysis is limited by the “last-seen well” principle, which defines stroke onset time. A significant minority of stroke patients (~15%) awake with their symptoms and are by definition ineligible for thrombolysis because they were “last-seen well” at the time they went to bed implying an interval that is most often greater than three hours.

Methods:

A single-centre prospective, safety study was designed to thrombolyse 20 subjects with stroke-on-awakening. Patients were eligible for inclusion if they were last seen well less than 12 hours previously, specifically including those who awoke from sleep with their stroke deficits. They had a baseline computed tomogram (CT) scan with an ASPECTS score greater than 5, no evidence of well-evolved infarction and a CT angiogram / Trans-cranial Doppler ultrasound study demonstrating an intracranial arterial occlusion. Patients fulfilled all other standard criteria for stroke thrombolysis. The primary outcome was safety defined by symptomatic ICH or death.

Results:

Among 89 screened patients, 20 were treated with thrombolysis. Two patients (10%) died due to massive carotid territory stroke and two patients (10%) died of stroke complications. Two patients (10%) showed asymptomatic intracerebral hemorrhage (ICH) (petechial hemorrhage) and none symptomatic ICH. Reasons for exclusion were: (a) ASPECTS ≤ 5 (29); (b) well-evolved infarcts on CT (19); (c) historical mRS > 2 (17); (d) no demonstrable arterial occlusion or were too mild to warrant treatment (10).

Conclusions:

Patients who awake with their deficits can be safely treated with thrombolysis based upon a tissue window defined by NCCT and CTA/TCD.

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 40 , Issue 1 , January 2013 , pp. 17 - 20
Copyright
Copyright © The Canadian Journal of Neurological 2013

References

1. Nadeau, JO, Fang, J, Kapral, MK, Silver, FL, Hill, MD. Outcome after stroke upon awakening. Can J Neurol Sci. 2005;32(2):232–6.Google Scholar
2. Fink, JN, Kumar, S, Horkan, C, et al. The stroke patient who woke up: clinical and radiological features, including diffusion and perfusion MRI. Stroke. 2002;33(4):988–93.Google Scholar
3. Hacke, W, Albers, G, Al-Rawi, Y, et al. The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke. 2005;36(1):66–73.CrossRefGoogle Scholar
4. Furlan, AJ, Eyding, D, Albers, GW, et al. Dose Escalation of Desmoteplase for Acute Ischemic Stroke (DEDAS): evidence of safety and efficacy 3 to 9 hours after stroke onset. Stroke. 2006; 37(5):1227–31.Google Scholar
5. Barber, PA, Hill, MD, Eliasziw, M, et al. Imaging of the brain in acute ischaemic stroke: comparison of computed tomography and magnetic resonance diffusion-weighted imaging. J Neurol Neurosurg Psychiatry. 2005;76(11):1528–33.Google Scholar
6. Hill, MD, Rowley, HA, Adler, F, et al. Selection of acute ischemic stroke patients for intra-arterial thrombolysis with pro-urokinase by using ASPECTS. Stroke. 2003;34(8):1925–31.Google Scholar
7. Hill, MD, Demchuck, AM, Tomsick, T, Palesch, YY, Broderick, JP. Using the baseline CT scan to select acute stroke patients for IVIA therapy. AJNR Am J Neuroradiol. 2006;27:1612–16.Google Scholar
8. Demchuk, AM, Hill, MD, Barber, PA, Silver, B, Patel, SC, Levine, SR. Importance of early ischemic computed tomography changes using ASPECTS in NINDS rtPA Stroke Study. Stroke. 2005;36 (10):2110–15.Google Scholar
9. Dzialowski, I, Hill, MD, Coutts, SB, et al. Extent of early ischemic changes on computed tomography (CT) before thrombolysis: prognostic value of the Alberta Stroke Program Early CT Score in ECASS II. Stroke. 2006;37(4):973–8.Google Scholar
10. Demchuk, AM, Burgin, WS, Christou, I, et al. Thrombolysis in brain ischemia (TIBI) transcranial Doppler flow grades predict clinical severity, early recovery, and mortality in patients treated with intravenous tissue plasminogen activator. Stroke. 2001;32 (1):89–93.Google Scholar
11. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333(24):1581–7.Google Scholar
12. Dzialowski, I, Weber, J, Doerfler, A, Forsting, M, von Kummer, R. Brain tissue water uptake after middle cerebral artery occlusion assessed with CT. J Neuroimaging. 2004;14(1):42–8.Google Scholar
13. von Kummer, R, Allen, KL, Holle, R, et al. Acute stroke: usefulness of early CT findings before thrombolytic therapy. Radiology. 1997;205(2):327–33.Google Scholar
14. von Kummer, R, Bourquain, H, Bastianello, S, et al. Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology. 2001;219(1):95–100.Google Scholar
15. Larrue, V, von Kummer, RR, Muller, A, Bluhmki, E. Risk factors for severe hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen activator: a secondary analysis of the European-Australasian Acute Stroke Study (ECASS II). Stroke. 2001;32(2):438–41.Google Scholar
16. Baron, JC, von Kummer, R, del Zoppo, GJ. Treatment of acute ischemic stroke. Challenging the concept of a rigid and universal time window. Stroke. 1995;26(12):2219–21.Google Scholar
17. von Kummer, R. The time concept in ischemic stroke: misleading. Stroke. 2000;31(10):2523–5.Google Scholar