| Objective:To evaluate the efficacy and safety of intravenous thrombolytic therapy with recombinant tissue plasminogen activator(rt-PA)in patients with wake-up ischemic stroke under the guidance of multimode magnetic resonance imaging compared with patients in the standard time window.Methods:The clinical datas of WUIS and acute ischemic stroke within 4.5 hours of symptom onset patients received intravenous thrombolytic therapy with rt-PA from January 2013 to March 2018 were collected.The patients in both groups completed multimode MRI before thrombolysis and met the imaging conditions of DWI-T2WI/FLAIR mismatch(hyper-intense in DWI and no hypo-intense change in T2WI or FLAIR.The baseline datas of the two groups,the results of laboratory examination,the scores of nerve function before and after thrombolytic therapy,the transformation of intracranial hemorrhage after thrombolysis,the mortality rate after thrombolysis and neurological functional outcome after 3 months were collected.The neurological function was evaluated according to the National Institutes of Health Stroke scale,and the transformation of intracranial hemorrhage after intravenous thrombolysis was defined according to the criterias established by the SITS-MOST、ECASSII、ECASSIII and NINDS studies,respectively.The modified Rankin scale(mRS)was used at 3 months after thrombolysis for neurological outcomes assessment,The favorable clinical outcome was defined as a score of 0 or 1 on the mRS,the poor clinical outcome was defined as a score of 4 to 6 on the mRS.Classification of cerebral infarction is based on TOAST etiological classification and OCSP clinical classification standard.Univariate and multivariate unconditional logistic regression models were used to analyze the predict factors of clinical outcome at 90 days.The baseline data and outcome of this study were compared with the WAKE-UP trial.Results:1)From January 2013 to March 2018,a total of 76 patients with WUIS received intravenous thrombolytic therapy(WUTS group)and 177 AIS patients(control group)received intravenous thrombolytic therapy within 4.5 hours.2)The level of serum uric acid was lower in the stroke group than that in the control group(median 276.0 μmol/L vs 304.0 μmol/L,P=0.039),and the level of homocysteine(HCY)in the stroke group was lower than that in the control group(median 11.4 umol/L vs 13.5 umol/L,P=0.006).9)The symptom recognition-arrival time of WUIS group was significantly longer than that of control group(median 2.0 h vs 1.3 h,P<0.001),the symptom recognition-MRI start time was significantly longer than that of control group(median 2.9 h vs 2.1 h,P<0.001),and the symptom recognition-thrombolysis time was significantly longer than that of control group(median 3.4 h vs 2.6 h,P<0.001).4)There was no significant difference in intracranial hemorrhage rate,mortality and NIHSS score on the 3rd and 7th day after thrombolysis between the two groups.Non-conditional Logistic regression analysis was performed with the dependent variable of good neurological outcome,suggesting that the baseline NIHSS score(OR=0.60,95%CI 0.43-0.83,P=0.002)and the time from symptom recognition to thrombolysis(OR=0.55,95%CI 0.34-0.87,P=0.01)were independent predictors of the outcome of the WUIS group patients with good neurological function.5)Compared with the baseline datas of the control group in WAKE-UP trial,the average onset ages of WUIS groups was younger(59.8±9.6 vs 65.2±11.9)than that of the control group(P<0.001),and the proportion of past stroke history was lower(2.6%vs 12.4%,P=0.015),while the baseline NIHSS score was higher(median 7 vs 6,P=0.0.006).The final normal-symptom recognition time was shorter(median 5.8h vs 7.0h,P<0.001),the symptom recognition-MR start time was longer(median 2.9h vs 2.6h,P=0.003),and the time of MR end-thrombolysis was shorter(median 22min vs 26min,P=0.032).The time of symptom recognition-thrombolysis was longer than that of WAKE-UP control group(median 3.4h 3.2h,P=0.011).The time from last normal to thrombolytic therapy was shorter than that of WAKE-UP trial group(median 9.7 h vs 10.4 h,P=0.001).6)Compared with the outcome of the control group in WAKE-UP trial,the mRS score of the WUIS groups was significantly lower than that in the WAKE-UP trial control group at 3 months(median 1 vs 2,P<0.001).The proportion of patients with good neurological outcomes was significantly higher than that of the WAKE-UP trial group(72.4%vs 41.8%,P<0.001),and the rate of poor neurological dysfunction was significantly lower than that of the WAKE-UP trial group(1.3%vs 18.3%,P<0.001).7)Compared with baseline datas of thrombolytic therapy group in WAKE-UP trial,the average onset age of WUIS group was lower(59.8±9.6 years vs 65.3±11.2 years,P<0.001)as well as the proportion of previous stroke history was lower(2.6%vs 14.6%),while the baseline NIHSS score was higher(median 7 vs 6,P=0.006)as well as the baseline NIHSS score was higher than that of WAKE-UP trial group(59.8±9.6 years vs 65.3±11.2 years,P<0.001).The time of final normal-symptom recognition was shorter(median 5.8 h vs 7.2 h,P<0.001),and the symptom recognition-MRI start time was longer(median 2.9h vs 2.6h,P=0.003).The time of symptom recognition-thrombolysis was longer(median 3.4 h vs 3.1h,P=0.003),and finally normal-thrombolysis time was shorter(median 9.7h vs 10.3h,P=0.004).8)Compared with the outcome of thrombolytic therapy group in WAKE-UP trial,the proportion of patients with good neurological outcomes was significantly higher in WUIS group than that in WAKE-UP trial group(72.4%vs 53.3%,P=0.003),and the proportion of poor neurological outcomes was significantly lower than that in WAKE-UP trial group(1.3%vs 13.5%,P<0.001).The ratio of sICH(with reference to NINDS test standard)was significantly lower than that in WAKE-UP trial thrombolytic group(0 vs 8%,P=0.006).Conclusions:1)Under the guidance of multimode magnetic resonance imaging,intravenous thrombolytic therapy was performed in WUIS and AIS of onset time window within 4.5 hours patients with DWI-T2WI/FLAIR mismatch in our center,the WUIS patients had the same favorable neurological outcome of 3 months and low hemorrhagic transformation as those AIS patients within 4.5 hours of onset time window.2)The efficacy and safety of intravenous thrombolytic therapy for WUIS patients in our study were better than those of WAKE-UP trial. |
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