Skip to main content Accessibility help
×
Home

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

Published online by Cambridge University Press:  23 September 2014


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
Corresponding
E-mail address:

Abstract:

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
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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):6673.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle ScholarPubMed
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):95100.CrossRefGoogle ScholarPubMed
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.CrossRefGoogle 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.CrossRefGoogle ScholarPubMed
17. von Kummer, R. The time concept in ischemic stroke: misleading. Stroke. 2000;31(10):2523–5.CrossRefGoogle ScholarPubMed

Full text views

Full text views reflects PDF downloads, PDFs sent to Google Drive, Dropbox and Kindle and HTML full text views.

Total number of HTML views: 0
Total number of PDF views: 162 *
View data table for this chart

* Views captured on Cambridge Core between September 2016 - 2nd December 2020. This data will be updated every 24 hours.

Access
Hostname: page-component-79f79cbf67-hp6v8 Total loading time: 0.494 Render date: 2020-12-02T11:21:42.330Z Query parameters: { "hasAccess": "1", "openAccess": "0", "isLogged": "0", "lang": "en" } Feature Flags last update: Wed Dec 02 2020 11:06:27 GMT+0000 (Coordinated Universal Time) Feature Flags: { "metrics": true, "metricsAbstractViews": false, "peerReview": true, "crossMark": true, "comments": true, "relatedCommentaries": true, "subject": true, "clr": false, "languageSwitch": true }

Send article to Kindle

To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

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

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

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

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

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

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *