title: Outcome and symptomatic bleeding complications of intravenous thrombolysis within 6 hours in MRI-selected stroke patients: comparison of a German multicenter study with the pooled data of ATLANTIS, ECASS, and NINDS tPA trials.
abstract: OBJECTIVE
  We compared outcome and symptomatic bleeding complications of intravenous tissue plasminogen activator (IV-tPA) within 6 hours of symptom onset in MRI-selected patients with acute middle cerebral artery infarction with the pooled data of the large stroke tPA trials.
  
  
  METHODS
  Patients were examined by perfusion-weighted and diffusion-weighted imaging < or =6 hours. Within 3 hours, patients were treated according to Second European-Australasian Acute Stroke Study (ECASS II) criteria. After 3 to 6 hours, treatment with IV-tPA was performed based on MRI findings. Favorable outcome was assessed after 90 days using a dichotomized modified Rankin scale score of 0 to 1. Intracerebral bleeding complications were assessed on follow-up MRI or computed tomography. Data were compared with the pooled placebo and pooled tPA patients of the ATLANTIS, ECASS, and National Institute of Neurological Disorders and Stroke (NINDS) tPA trials.
  
  
  RESULTS
  From 174 MRI-selected tPA patients, 62% (n=108) were treated in < or =3 hours and 38% (n=66) after 3 to 6 hours. Favorable outcome was more frequent in MRI-selected tPA patients (48% [95% CI, 39 to 54]) compared with pooled placebo (33% [95% CI, 31 to 36]; P<0.001) and pooled tPA patients (40% [95% CI, 37 to 42]; P=0.046). Odds ratios for favorable outcome in the MRI-selected tPA group were 1.82 (1.32 to 2.51) compared with the pooled placebo and 1.39 (1.01 to 1.92) compared with the pooled tPA group. The rate of symptomatic intracerebral hemorrhage in MRI-selected tPA patients (3% [95% CI, 0 to 5]) was lower than in the pooled tPA group (8% [95% CI, 7 to 10]; P=0.012) and comparable to the pooled placebo group (2% [95% CI, 1 to 3]; P=0.392).
  
  
  CONCLUSIONS
  This study supports that it is safe and effective to expand the time window for IV-tPA up to 6 hours in patients with tissue at risk as defined by MRI.
authors.affiliation: Klinik und Poliklinik für Neurologie, NeuroZentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany. thomalla@uke.uni-hamburg.de
authors.forename: Götz
authors.initials: G
authors.lastname: Thomalla
authors.forename: Christian
authors.initials: C
authors.lastname: Schwark
authors.forename: Jan
authors.initials: J
authors.lastname: Sobesky
authors.forename: Erich
authors.initials: E
authors.lastname: Bluhmki
authors.forename: Jochen B
authors.initials: JB
authors.lastname: Fiebach
authors.forename: Jens
authors.initials: J
authors.lastname: Fiehler
authors.forename: Olivier
authors.initials: O
authors.lastname: Zaro Weber
authors.forename: Thomas
authors.initials: T
authors.lastname: Kucinski
authors.forename: Eric
authors.initials: E
authors.lastname: Juettler
authors.forename: Peter A
authors.initials: PA
authors.lastname: Ringleb
authors.forename: Hermann
authors.initials: H
authors.lastname: Zeumer
authors.forename: Cornelius
authors.initials: C
authors.lastname: Weiller
authors.forename: Werner
authors.initials: W
authors.lastname: Hacke
authors.forename: Peter D
authors.initials: PD
authors.lastname: Schellinger
authors.forename: Joachim
authors.initials: J
authors.lastname: Röther
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage; D002986:Clinical Trials as Topic; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods*; D005260:Female; D005858:Germany; D006801:Humans; D007262:Infusions, Intravenous; D018810:Magnetic Resonance Angiography / Q000379:methods*; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010919:Placebos; D020521:Stroke; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D010919:Placebos; D010959:Tissue Plasminogen Activator