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(Stroke. 2005;36:602.)
© 2005 American Heart Association, Inc.

Original Contributions

Safety and Efficacy of Intravenous Tissue Plasminogen Activator Stroke Treatment in the 3- to 6-Hour Window Using Multimodal Transcranial Doppler/MRI Selection Protocol

Marc Ribo, MD, PhD; Carlos A. Molina, MD, PhD; Alex Rovira, MD; Manuel Quintana; Pilar Delgado, MD; Joan Montaner, MD, PhD; Elisenda Grivé, MD; Juan F. Arenillas, MD, PhD José Álvarez-Sabín, MD, PhD

From the Unitat Neurovascular (M.R., C.A.M., M.Q., P.D., J.M., J.F.A., J.A.-S.), Department of Neurology, and Magnetic Resonance Unit (M.R., A.R., E.G.), Department of Radiology, Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Spain; and the Stroke Program (M.R.), Department of Neurology, University of Texas Health Science Center, Houston.

Correspondence to Dr Marc Ribo, the University of Texas Houston Medical School, 6431 Fannin, MSB 7.126, Houston, TX 77030. E-mail marcriboj{at}hotmail.com

Background— Growing data point toward intravenous tissue plasminogen activator (tPA) benefit after 3 hours in selected stroke patients. We aim to study safety and efficacy of tPA treatment in the 3- to 6-hour window using multimodal transcranial Doppler (TCD)/MRI selection criteria.

Methods— We studied patients with acute middle cerebral artery (MCA) occlusion. Patients within 0 to 3 hours from symptom onset (A) were treated according to standard computed tomography criteria. Treatment within 3 to 6 hours (B) was decided according to TCD/MRI protocol. Continuous TCD assessed clot location and recanalization. National Institutes of Health Stroke Scale (NIHSS) at 24 hours assessed neurological improvement/worsening and modified Rankin score <3 functional independence at third month.

Results— Of 135 patients, 56 were in the 3- to 6-hour window. Only 13 (23%) patients within 3 to 6 hours did not meet MRI inclusion criteria. Finally, 122 patients were treated with tPA: A, 79 (65%); B, 43 (35%). Median time to treatment was: A, 136 minutes (range 60 to 180); B, 223 (185 to 360). There were no differences in demographic parameters, baseline NIHSS (A, 17; B, 17; P=0.89), and occlusion location (proximal MCA A, 65.8%; B, 74.4%; P=0.28). Recanalization rates at 2 hours were similar (A, 49.3%; B, 55.2%; P=0.33), as were hemorrhagic transformation rates (asymptomatic: A, 18.7%, B, 26.6%, P=0.43; symptomatic: A, 3.75%, B, 2.38%, P=0.66). Improvement at discharge was similar in both groups (NIHSS dropped 6.3 points [A] versus 6.1 [B]; P=0.86). However, the number of patients who benefited from treatment was slightly higher in the 3- to 6-hour group (A, 58.2%; B, 76.2%; P=0.05), whereas the same rate of patients worsened (A, 11.4%; B, 7.1%; P=0.46). At 3 months, the rate of independent patients was: A, 42% versus B, 38% (P=0.74).

Conclusions— tPA treatment can be safely and effectively extended to the 3- to 6-hour window using TCD/MRI selection criteria. Not using these criteria in the 3- to 6-hour window avoids potentially effective treatment in a high rate of patients.

Key Words: computed tomography • imaging, diffusion-weighted • magnetic resonance angiography • stroke, acute • thrombolysis • tissue plasminogen activator • ultrasonography, Doppler • ultrasonography, Doppler, transcranial

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