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

Published online by Cambridge University Press:  23 September 2014

Michael D. Hill ,
Carol Kenney ,
Imanuel Dzialowski ,
Jean-Martin Boulanger ,
Andrew M. Demchuk ,
Philip A. Barber ,
Timothy W.J. Watson ,
Nicolas U. Weir ,
Alastair M. Buchan  and
Calgary Stroke Program
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
*
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Foothills Hospital, Rm 1242A, 1403 29th Street NW, Calgary, Alberta, T2N 2T9, Canada. email: michael.hill@ucalgary.ca
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Abstract:

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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
Information
Canadian Journal of Neurological Sciences , Volume 40 , Issue 1 , January 2013 , pp. 17 - 20
Copyright
Copyright © The Canadian Journal of Neurological 2013

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