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.
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.
Thomalla
Götz
G
Klinik und Poliklinik für Neurologie, NeuroZentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany. thomalla@uke.uni-hamburg.de
Schwark
Christian
C
Sobesky
Jan
J
Bluhmki
Erich
E
Fiebach
Jochen B
JB
Fiehler
Jens
J
Zaro Weber
Olivier
O
Kucinski
Thomas
T
Juettler
Eric
E
Ringleb
Peter A
PA
Zeumer
Hermann
H
Weiller
Cornelius
C
Hacke
Werner
W
Schellinger
Peter D
PD
Röther
Joachim
J
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
D010919:Placebos; D010959:Tissue Plasminogen Activator