1
|
Thomalla G, Boutitie F, Ma H, Koga M, Ringleb P, Schwamm LH, Wu O, Bendszus M, Bladin CF, Campbell BCV, Cheng B, Churilov L, Ebinger M, Endres M, Fiebach JB, Fukuda-Doi M, Inoue M, Kleinig TJ, Latour LL, Lemmens R, Levi CR, Leys D, Miwa K, Molina CA, Muir KW, Nighoghossian N, Parsons MW, Pedraza S, Schellinger PD, Schwab S, Simonsen CZ, Song SS, Thijs V, Toni D, Hsu CY, Wahlgren N, Yamamoto H, Yassi N, Yoshimura S, Warach S, Hacke W, Toyoda K, Donnan GA, Davis SM, Gerloff C. Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data. Lancet 2020; 396:1574-1584. [PMID: 33176180 PMCID: PMC7734592 DOI: 10.1016/s0140-6736(20)32163-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/03/2020] [Accepted: 10/12/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patients who have had a stroke with unknown time of onset have been previously excluded from thrombolysis. We aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers. METHODS We did a systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020. Randomised trials of intravenous alteplase versus standard of care or placebo in adults with stroke with unknown time of onset with perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch were eligible. The primary outcome was favourable functional outcome (score of 0-1 on the modified Rankin Scale [mRS]) at 90 days indicating no disability using an unconditional mixed-effect logistic-regression model fitted to estimate the treatment effect. Secondary outcomes were mRS shift towards a better functional outcome and independent outcome (mRS 0-2) at 90 days. Safety outcomes included death, severe disability or death (mRS score 4-6), and symptomatic intracranial haemorrhage. This study is registered with PROSPERO, CRD42020166903. FINDINGS Of 249 identified abstracts, four trials met our eligibility criteria for inclusion: WAKE-UP, EXTEND, THAWS, and ECASS-4. The four trials provided individual patient data for 843 individuals, of whom 429 (51%) were assigned to alteplase and 414 (49%) to placebo or standard care. A favourable outcome occurred in 199 (47%) of 420 patients with alteplase and in 160 (39%) of 409 patients among controls (adjusted odds ratio [OR] 1·49 [95% CI 1·10-2·03]; p=0·011), with low heterogeneity across studies (I2=27%). Alteplase was associated with a significant shift towards better functional outcome (adjusted common OR 1·38 [95% CI 1·05-1·80]; p=0·019), and a higher odds of independent outcome (adjusted OR 1·50 [1·06-2·12]; p=0·022). In the alteplase group, 90 (21%) patients were severely disabled or died (mRS score 4-6), compared with 102 (25%) patients in the control group (adjusted OR 0·76 [0·52-1·11]; p=0·15). 27 (6%) patients died in the alteplase group and 14 (3%) patients died among controls (adjusted OR 2·06 [1·03-4·09]; p=0·040). The prevalence of symptomatic intracranial haemorrhage was higher in the alteplase group than among controls (11 [3%] vs two [<1%], adjusted OR 5·58 [1·22-25·50]; p=0·024). INTERPRETATION In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death. FUNDING None.
Collapse
Affiliation(s)
- Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France; Université Lyon 1, Villeurbanne, France; Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Christopher F Bladin
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Bruce C V Campbell
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Leonid Churilov
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik für Neurologie Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany; German Centre of Cardiovascular Research, Berlin, Germany; German Center of Neurodegenerative Diseases, Berlin, Germany
| | - Jochen B Fiebach
- Centrum für Schlaganfallforschung Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Lawrence L Latour
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven, University of Leuven, Leuven, Belgium; VIB Center for Brain and Disease Research Leuven, Belgium; Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Christopher R Levi
- The Department of Neurology, Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Didier Leys
- Université de Lille, Inserm U1171, Lille, France
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CarMeN Laboratory, INSERM U1060/INRA 1397, Lyon, France
| | - Mark W Parsons
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnòstic per la Imatge, Hospital Dr Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Peter D Schellinger
- Universitätsklinik für Neurologie, Mühlenkreiskliniken, Johannes Wesling Klinikum Minden, Universitätsklinikum der Ruhr-Universität Bochum, Minden, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Shlee S Song
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Danilo Toni
- Department of Human Neurosciences, University of Rome "La Sapienza", Rome, Italy
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nawaf Yassi
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Steven Warach
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|