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(Stroke. 2007;38:2640.)
© 2007 American Heart Association, Inc.

Original Contributions

MRI-Based and CT-Based Thrombolytic Therapy in Acute Stroke Within and Beyond Established Time Windows

An Analysis of 1210 Patients

Peter D. Schellinger, MD, PhD; Götz Thomalla, MD; Jens Fiehler, MD, PhD; Martin Köhrmann, MD; Carlos A. Molina, MD, PhD; Tobias Neumann-Haefelin, MD, PhD; Marc Ribo, MD; Oliver C. Singer, MD; Olivier Zaro-Weber, MD Jan Sobesky, MD, PhD

From the Department of Neurology (P.D.S., M.K.), University of Erlangen, Erlangen, Germany; the Department of Neurology (P.D.S., M.K.), University of Heidelberg, Heidelberg, Germany; the Departments of Neurology (G.T.) and Neuroradiology (J.F.), University of Hamburg, Hamburg, Germany; the Department of Neurology (O.Z.-W., J.S.), University of Cologne, Cologne, Germany; the Department of Neurology (T.N.-H., O.C.S.), University of Frankfurt, Frankfurt, Germany; and the Department of Neurology (C.A.M., M.R.), Autonomic University of Barcelona–Hospital Vall d’Hebron, Barcelona, Spain.

Correspondence to Peter D. Schellinger, MD, PhD, Professor and Vice Chairman, Department of Neurology, University of Erlangen, Schwabachanlage 6, D-91054 Erlangen, Germany. E-mail Peter.Schellinger{at}uk-erlangen.de

Background and Purpose— The use of intravenous thrombolysis is restricted to a minority of patients by the rigid 3-hour time window. This window may be extended by using modern imaging-based selection algorithms. We assessed safety and efficacy of MRI-based thrombolysis within and beyond 3 hours compared with standard CT-based thrombolysis.

Methods— Five European stroke centers pooled the core data of their CT- and MRI-based prospective thrombolysis databases. Safety outcomes were predefined as symptomatic intracranial hemorrhage and mortality. Primary efficacy outcome was a favorable outcome (modified Rankin Scale 0 to 1). We performed univariate and multivariate analyses for all end points, including age, National Institutes of Health Stroke Scale, treatment group (CT <3 hours, MRI <3 hours and >3 hours), and onset to treatment time as variables.

Results— A total of 1210 patients were included (CT <3 hours: N=714; MRI <3 hours: N=316; MRI >3 hours: N=180). Median age, National Institutes of Health Stroke Scale, and onset to treatment time were 69, 67, and 68.5 years (P=0.66); 12, 13, and 14 points (P=0.019); and 130, 135, and 240 minutes (P<0.001). Symptomatic intracranial hemorrhage rates were 5.3%, 2.8%, and 4.4% (P=0.213); mortality was 13.7%, 11.7%, and 13.3% (P=0.68). Favorable outcome occurred in 35.4%, 37.0%, and 40% (P=0.51). Age and National Institutes of Health Stroke Scale were independent predictors for all safety and efficacy outcomes. The overall use of MRI significantly reduced symptomatic intracranial hemorrhage (OR: 0.520, 95% CI: 0.270 to 0.999, P=0.05). Beyond 3 hours, the use of MRI significantly predicted a favorable outcome (OR: 1.467; 95% CI: 1.017 to 2.117, P=0.040). Within 3 hours and for all secondary end points, there was a trend in favor of MRI-based selection over standard <3-hour CT-based treatment.

Conclusion— Despite significantly longer time windows and significantly higher baseline National Institutes of Health Stroke Scale scores, MRI-based thrombolysis is safer and potentially more efficacious than standard CT-based thrombolysis.

Key Words: diffusion–perfusion mismatch • intravenous thrombolysis • MRI • stroke

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