Treating ischaemic stroke with intravenous tPA beyond 4.5 hours under the guidance of a MRI DWI/T2WI mismatch was safe and effective.

Purpose: Clinical trials have provided evidence that treating patients with acute ischaemic stroke (AIS) beyond 4.5 hours was feasible. Among them using MRI diffusion-weighted imaging/fluid attenuation inversion response (DWI/FLAIR) mismatch to guide intravenous tissue plasminogen activator (tPA) was successful. Our study explored the outcome and safety of using DWI/T2-weighted imaging (T2WI) mismatch to guide intravenous tPA therapy for patients with AIS between 4.5 hours and 12 hours of onset. Method: This was a retrospective study. Records of 1462 AIS patients with the time of onset of <12 hours were reviewed. Those had MRI rapid sequence study and had hyperintense signal on DWI but normal T2WI and received intravenous tPA up to 12 hours of onset were included in the analysis. Their demographics, risk factors, post-tPA complications, National Institutes of Health Stroke Scale (NIHSS) scores and outcome were recorded and analyse. χ2 was used to compare the intergroup variables. SAS was used to perform statistical calculation. A p<0.05 was considered statistically significant. Results: Of 1462 identified, 601 (41%) patients were entered into the final analysis. Among them, 327 (54%) had intravenous tPA within 4.5 hours of onset and 274 (46%) were treated between 4.5-12 hours. After intravenous tPA, 426 cases (71%) had >4 pints of improvement on NIHSS score within 24 hours. Postintravenous tPA, 32 (5.32%) cases had haemorrhagic transformation. 26 (4.33%) were asymptomatic ICH and 4 (0.67%) died. At 90 days, 523 (87%) achieved a modified Rankin scale of 0-2. Conclusion: Using MRI DWI/T2WI mismatch to identify patients with AIS for intravenous tPA between 4.5 hours and 12 hours was safe and effective. The outcome was similar to those used DWI/PWI or DWI/FLAIR mismatch as the screening tool. However, obtaining DWI/T2WI was faster and avoided the need of contrast material.

Ginsenoside Represses Symptomatic Intracerebral Hemorrhage after Recombinant Tissue Plasminogen Activator Therapy by Promoting Transforming Growth Factor-ß1.

BACKGROUND: Currently, the most effective treatment for brain ischemic stroke is recombinant tissue plasminogen activator (rt-PA); however, increased incidence of symptomatic intracerebral hemorrhage severely reduced its favorable treatment outcome. METHODS: We aimed to investigate the effect of ginsenoside (Gs) on symptomatic intracerebral hemorrhage after rt-PA treatment. Stroke patients were randomly divided into 2 treatment groups, one receiving rt-PA + placebo (Pc) and the other rt-PA + Gs. Twenty-four hours after the treatment, outcomes were assessed with transcranial Doppler (TCD) ultrasonography and National Institutes of Health Stroke Scale (NIHSS), and plasma levels of transforming growth factor-ß1 (TGF-ß1), matrix metalloproteinase (MMP)-2, and MMP-9 were also measured. After initial cotreatment, the patients were continuously administered with either Pc or Gs, and the treatment outcomes at 7 days were assessed with TCD, NIHSS, modified Rankin scale (MRS), and Glasgow outcome scale (GOS). RESULTS: Cotreatment of rt-PA with Gs significantly improved outcomes in patients compared to the Pc group, as indicated by improved TCD and NIHSS scores and reduced incidence of symptomatic intracerebral hemorrhage, which could be attributed to a Gs-induced increase in TGF-ß1 and a decrease in both MMP-2 and MMP-9 serum levels. Seven days of Gs treatment also significantly improved outcomes in patients compared to the Pc group, assessed by TCD, NIHSS, MRS, and GOS. CONCLUSION: Our study supports the clinical use of Gs as a potential supplement with rt-PA treatment, which reduces symptomatic intracerebral hemorrhage, therefore improving the treatment outcome of stroke patients.

Comparison of fast MRI-based individual thrombolysis therapy for patients with superacute infarction.

BACKGROUND: The aim of this study is to investigate the outcomes of magnetic resonance imaging (MRI)-based individual thrombolysis therapy using recombinant tissue plasminogen activator (rt-PA) in patients with superacute infarction, comparing the outcome in 1 group of patients treated within 4.5 hours compared with 4.5- to 12-hour window treatment group. METHODS: We studied 135 patients stratified to 2 different groups based on whether they presented with stroke symptoms within 4.5 hours (4.5-hour group, 72 patients) or between 4.5 and 12 hours (4.5- to 12-h group, 63 patients). All patients were treated with rt-PA after MRI confirmed superacute ischemic stroke (hyperintense in diffusion-weighted imaging but no hypointense change in T2-weighted image (T2WI) or fluid-attenuated inversion recovery). Clinical neurologic deficit was evaluated using the National Institutes of Health Stroke Scale on admission, at 24 hours, and 7 days later. A 90-day clinical outcome was assessed using the modified Rankin Scale (mRS). RESULTS: There was no significant difference in the clinical outcome between the patients treated with thrombolysis within the first 4.5 hours and those treated between 4.5 and 12 hours. The 2 groups both had recanalization, mRS, and favorable outcome at 90 days (P > .05). CONCLUSIONS: Our study suggested that fast MR-based thrombolysis using rt-PA was safe and reliable in superacute infarction within 4.5 hours and 4.5-12 hours poststroke.

Susceptibility-weighted imaging for cerebral microbleed detection in super-acute ischemic stroke patients treated with intravenous thrombolysis.

OBJECTIVE: Fast magnetic resonance imaging (MRI) and susceptibility-weighted imaging (SWI) methods may provide more accurate detection of the highly variant time window for successful intravenous (IV) thrombolytic drug treatment (averaging 3 hours) for cerebral microbleeds (CMBs) in acute stroke patients. METHODS: This prospective study applies fast MRI and SWI for examination of 279 prescreened ischemic stroke patients within 12 hours of stroke onset. One hundred and sixty-two (58.1%) of 279 patients were diagnosed with super-acute ischemic stroke with restricted diffusion, hyperintense diffusion-weighted imaging signals, and no ischemic change in T2-weighted imaging, fluid-attenuated inversion recovery, or T1-weighted imaging signals. Recombinant tissue plasminogen activator IV thrombolysis was administered to 113 (69.75%) patients (thrombolysis group). All patients underwent regular sequence MRI and SWI follow-up. RESULTS: Computed tomography and MRI sequence scans revealed hemorrhagic transformations in 13 (11.50%) thrombolysis and four (8.16%) non-thrombolysis group patients. MRI-guided thrombolysis treatment produced no significant differences between the two groups. SWI revealed new CMBs in 46 (40.70%) and nine (18.37%) thrombolysis and non-thrombolysis group patients, respectively. Significantly better National Institutes of Health stroke scale (24 hours) (P<0.05), modified Rankin scale (90 days) (P<0.01), and life quality Barthal index scores were observed in CMB patients (P<0.01). CONCLUSIONS: SWI revealed higher CMB incidence and clinical improvement in recombinant tissue plasminogen activator IV thrombolysis-treated super-acute ischemic stroke patients, suggesting that CMBs may indicate vascular re-canalization/reperfusion. Thus, SWI can be applied to extend individual patient windows for thrombolytic treatment beyond general recommendations of treatment within 3 hours, allowing treatment up to 12 hours from stroke onset.

Clinical outcomes of fast MRI-based trombolysis in wake-up strokes compared to superacute ischemic strokes within 12 hours.

BACKGROUND: It is unknown whether thrombolysis is beneficial in patients with Wake-Up Ischemic Strokes (WUIS). This study compares the clinical outcomes of MRI-based intravenous thrombolysis in patients with hyperacute ischemic stroke presenting within 12 hours of symptom onset against WUIS patients receiving the same therapy. METHODS: Patients presenting within 12 hours of acute stroke symptom onset and those with WUIS confirmed by CT, and without intracranial hemorrhage, were encouraged to perform an emergent brain MRI scan to confirm the diagnosis of hyperacute ischemic stroke [hyper-intense in diffusion-weighted imaging (DWI) and no hypo-intense change in T2-weighted imaging (T2WI) or FLAIR]. These patients then received intravenous thrombolytic therapy with tissue-type plasminogen activator (rt-PA). All patients were divided into either stroke presenting within 12 hours or WUIS. The clinical outcomes were assessed by the modified Rankin Scale (mRS) and the Barthal Index (BI) at baseline and at 90 days after the thrombolysis therapy. RESULTS: A total of 427 patients presenting with stroke like symptoms were given a MRI scan. Of these, 240 patients had confirmed diagnosis of hyperacute ischemic stroke (WUIS, n = 68, 68/116 = 58·62% versus within 12 hour, n = 172, 172/311 = 55·3%). Altogether, 186 patients (138 in within 12 hours group, and 48 in WUIS group) received intravenous thrombolytic therapy with rt-PA. No significant differences were found in clinical outcomes between the two groups at the baseline and at 90 days after the thrombolysis therapy. Also, no difference was found in the incidence rate of secondary hemorrhage (including both of asymptomatic and symptomatic) and mortality rate between the two groups. CONCLUSION: Our study suggested that MRI-based intravenous thrombolysis is safe and effective in both of patients' hyperacute stroke within 12 hours of symptom onset and WUIS.

Fast multimode MRI based emergency assessment of hyperacute stroke thrombolysis.

OBJECTIVE: To investigate the value of fast multimode magnetic resonance imaging (MRI) based emergency assessment hyperacute stroke thrombolysis. METHODS: One hundred and twenty four patients with 12 hour window acute ischemic strokes were examined by fast multimode MRI, and among them, 46 patients with hyperacute cerebral infarction confirmed by fast multimode MRI were treated by recombinant tissue plasminogen activator and followed up periodically by MRI. RESULTS: The 46 patients selected by fast multimode MRI to receive thrombolytics demonstrated clinical improvement with 90 days modified Rankin scale scores < or =2 and life quality Barthal index of 80-100. Six patients developed asymptomatic intracranial hemorrhage (13.0%) 1-7 days after receiving thrombolytics. CONCLUSIONS: Patients suffering from hyperacute ischemic cerebral infarction that are strong candidates for intravenous thrombolytic therapy can be identified by multimode MRI, especially for those whose time windows were undefined or beyond 3 hours after symptom onset. Fast multimodal MRI based selection of the hyperacute stroke model is more feasible compared with the traditional diffusion weighted imaging/perfusion weighted imaging mismatch model for the emergency assessment of hyperacute stroke thrombolysis.

The application of fast multiparametric protocol MRI-based thrombolysis with rt-PA hyperacute cerebral infarction.

OBJECTIVE: To investigate the value of fast multiparametric protocol magnetic resonance imaging (MRI)-based thrombolysis in hyperacute cerebral infarction. METHODS: Seventy-seven patients with acute ischemic stroke were examined by multiparametric protocol MRI and among them, 12 patients with hyperacute cerebral infarction were treated by recombinant tissue plasminogen activator (rt-PA) and followed up periodically by MRI. RESULTS: The 12 patients selected by FMPMRI to receive thrombolysis demonstrated clinical improvement, with 90 day modified Rankin scale scores (mRs) < or = 2 and life quality Barthel index (BI) of 80-100. The only complication involved one patient (8.3%) who developed an asymptomatic intracranial hemorrhage 3 weeks after receiving thrombolytics. CONCLUSION: Multiparametric protocols have significant clinical potential for the treatment of hyperacute stroke patients who are candidates for receiving intravenous thrombolytic therapy. Our data suggest that patients suffering from hyperacute ischemic cerebral infarction that are strong candidates for intravenous thrombolytic therapy can be identified by multiparametric protocol MRI, especially to those whose time windows were undefined or beyond 3 hours after symptom onset.