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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.
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.
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).
Patients who awake with their deficits can be safely treated with thrombolysis based upon a tissue window defined by NCCT and CTA/TCD.
The computed tomogram angiography (CTA) ‘spot sign’ describes foci of intralesional enhancement associated with hematoma expansion in primary intracerebral hemorrhage patients. A consistent radiological definition is required for two proposed recombinant Factor VIIa trials planning patient dichotomization according to ‘spot sign’ presence or absence. We propose radiological criteria for diagnosis of the CTA ‘spot sign’ and describe different morphological patterns.
Material and Methods:
A prospective cohort of 36 consecutive patients presenting with primary intracerebral hemorrhage (ICH) were enrolled in a multicenter collaborative study, and have been included for the present analysis. Three reviewers analyzed the CTA studies in a blinded protocol. Analysis of specific ICH and ‘spot sign’ features was performed including prevalence, number, size, location, morphology and Hounsfield unit density.
Twelve of thirty-six patients (33%) demonstrated a total of 19 enhancing foci consistent with the CTA ‘spot sign’. Mean maximal axial ‘spot sign’ dimension was 3.7±2.2 mm and mean density was 216±57.7 HU. No significant differences in age or blood pressure (p=0.7), glucose (p=0.9), INR/PTT (p=0.3 and 0.4) or hematoma location (p=0.3) were demonstrated between patients with or without the ‘spot sign’. Consensus definition and classification criteria for the CTA ‘spot sign’ are proposed.
The ‘spot sign’ is defined as spot-like and/or serpiginous foci of enhancement, within the margin of a parenchymal hematoma without connection to outside vessels. The ‘spot sign’ is greater than 1.5 mm in maximal dimension and has a Hounsfield unit density at least double that of background hematoma density.
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