Evidence-based approach to imaging-based thrombolysis beyond the 4.5hours window

1. Evidence-based approach to imaging-based thrombolysis beyond the 4.5hours window Γεώργιος Ντάιος Παθολογική Κλινική & Ομώνυμο Ερευνητικό Εργαστήριο Ιατρική Σχολή Πανεπιστημίου Θεσσαλίας Heart Vessels Stroke Αthens, 27-01-2013

2. Disclosures • Support to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim;Bristol Myers Squibb; Galenica. • Honoraria: Quintiles; CHUV. • Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. • National coordinator (Greece) for the ENOS trial.

3. Patient P. M., 77years-old • 77 years old man found in bed with aphasia and right hemisyndrome • Admission: 7.5 hours after last-well time - NIHSS score = 20

4. Patient P. M., 77years-old

7. «Intravenous rtPAis recommended within 4.5 hoursof onset of ischaemic stroke (Class I, Level A)»

8. Patient P. M., 77years-old

9. The ischemic penumbra

10. The sooner, the better 4.5 hours * * • Lancet 2004; 363: 768–74

11. Patient P. M., 77years-old Penumbra: 207.8ml Initial infarct: 14.1ml

12. Patient P. M., 77years-old

13. Patient P. M., 77years-old Final infarct: 15.7ml Initial infarct: 14.1ml 5-days DWI-MRI

14. 300 4.5h 250 200 Number of cases 150 Unknown onset (n=454) 100 50 0 3 6 9 12 15 18 21 24 Time (hours) Known onset (n=1075) Michel P, Ntaios G, et al. Stroke2010; 41:2491-8.

33. Outcome

34. 66 % 16.6% Independence at 3 months (Rankin score ≤2) 80% 60% 40% 20% 0% 4/6 1/6 rtPA Placebo

35. 75 % 20 % Recanalization 80% 60% 40% 20% 0% 3/4 1/5 rtPA Placebo

37. Recanalization

38. Symptomatic hemorrhage

39. Clinical outcome

40. Mortality

41. Επανασυραγγοποιεί τη βλάβη • Αυξάνει την αιμορραγική μετατροπή • Δεν βελτιώνει την κλινική έκβαση ή τη θνητότητα

42. Take home messages