MRI Mismatch Extends Alteplase to Unknown-Onset Stroke

WAKE-UP demonstrates that diffusion-weighted imaging/FLAIR mismatch can select wake-up and unknown-onset stroke patients for intravenous alteplase, expanding thrombolysis eligibility beyond the fixed 4.5-hour clock.

alteplasetissue plasminogen activatorthrombolysisacute ischemic strokewake-up strokeDWI-FLAIR mismatchMRIrandomized controlled trialneurologyWAKE-UP Neurology / Neuropharmacology

Background Information

MRI-guided thrombolysis may benefit stroke of unknown onset.

This study explores extending thrombolysis to stroke patients with unknown onset times using MRI criteria, potentially increasing treatment options. Patients treated with intravenous alteplase showed a 53.3% favorable outcome compared to 41.8% with placebo, despite a higher rate of intracranial hemorrhage. Findings suggest potential benefits of alteplase for stroke patients with unknown onset times, though increased risk of bleeding must be considered. MRI-guided thrombolysis for unknown onset stroke may improve outcomes but with increased bleeding risk.

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Authors: Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, Cheripelli B, Cho TH, Fazekas F, Fiehler J, Ford I, Galinovic I, Gellissen S, Golsari A, Gregori J, Günther M, Guibernau J, Häusler KG, Hennerici M, Kemmling A, Marstrand J, Modrau B, Neeb L, Perez de la Ossa N, Puig J, Ringleb P, Roy P, Scheel E, Schonewille W, Serena J, Sunaert S, Villringer K, Wouters A, Thijs V, Ebinger M, Endres M, Fiebach JB, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Gerloff C, WAKE-UP Investigators

Citation: Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. The New England journal of medicine. 2018;379(7):611-622. doi:10.1056/NEJMoa1804355

Article Links: PubMed · Journal / DOI

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Executive Summary

Study Design

Patient Population

Primary Outcomes

Secondary Outcomes & Safety Profile

Pharmacist Implications

Clinical Pearls

Limitations

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