Evidence-based approach to imaging-based thrombolysis

beyond the 4.5hours window

Heart Vessels StrokeΑthens, 27-01-2013

Γ ε ώ ρ γ ι ο ς Ν τ ά ι ο ς

Π α θ ο λ ο γ ι κ ή Κ λ ι ν ι κ ή & Ο μ ώ ν υ μ ο Ε ρ ε υ ν η τ ι κ ό Ε ρ γ α σ τ ή ρ ι ο

Ι α τ ρ ι κ ή Σ χ ο λ ή Π α ν ε π ι σ τ η μ ί ο υ Θ ε σ σ α λ ί α ς

Disclosures

• Support to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Bristol Myers Squibb; Galenica.

• Honoraria: Quintiles; CHUV.

• Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis.

• National coordinator (Greece) for the ENOS trial.

Patient P. M., 77years-old

- 77 years old man found in bed with aphasia and right hemisyndrome

- Admission: 7.5 hours after last-well time

- NIHSS score = 20

Patient P. M., 77years-old

«Intravenous rtPA is recommended within 4.5 hours

of onset of ischaemic stroke (Class I, Level A)»

Patient P. M., 77years-old

The ischemic penumbra

The sooner, the better

**

Lancet 2004; 363: 768–74

4.5 hours

Patient P. M., 77years-old

Penumbra: 207.8ml

Initial infarct: 14.1ml

Patient P. M., 77years-old

Patient P. M., 77years-old

5-days DWI-MRI

Final infarct: 15.7ml

Initial infarct: 14.1ml

Num

ber o

f cas

es

0

50

100

150

200

250

300

3 6 9 12 15 18 21 24

Time (hours)

Known onset(n=1075)

Unknown onset(n=454)

4.5h

Michel P, Ntaios G, et al. Stroke 2010; 41:2491-8.

Outcome

OutcomerTPA

groupn=6

Placebo group

n=6Symptomatic hemorrhagic transformation at 24hours/4 days

0/0 0/0

Asymptomatic hemorrhagic transformations at 24hours (CT)

2 2

Asymptomatic hemorrhagic transformations at 4days (MRI)

3 2

Mortality at 7/90 days 0/0 0/0

Salvaged brain tissue (cm3)* 84 (44-206)

29 (8-105)

Independence at 3 months (Rankin score ≤2)

80%

60%

40%

20%

0%

rtPA Placebo

16.6%

66 %

4/6

1/6

Recanalization

80%

60%

40%

20%

0%

20 %

75 %

3/4

1/5

rtPA Placebo

Recanalization

Symptomatic hemorrhage

Clinical outcome

Mortality

- Επανασυραγγοποιεί τη βλάβη

- Αυξάνει την αιμορραγική μετατροπή

- Δεν βελτιώνει την κλινική έκβαση ή τη θνητότητα

Take home messages