R.E.B.E.L.EM - February 06, 2020 - By Mark Ramzy
"Author’s Conclusions:
Patients with ischaemic stroke 4.5 – 9 h from stroke onset or wake-up stroke with salvageable brain tissue who were treated with alteplase achieved better functional outcomes than did patients given placebo. The rate of symptomatic intracerebral haemorrhage was higher with alteplase, but this increase did not negate the overall net benefit of thrombolysis.
Our Conclusion:
For patients without large vessel occlusion, this data pushes to expand the number of patients with AIS who may benefit from systemic alteplase. (ie. 4.5 – 9 hour window + wake up strokes). Functional independence is a subjective outcome that varies from patient to patient and is difficult to categorize with a single scoring system. Furthermore, not all institutions have access to the advanced neuroimaging modalities used in this study which limits its utility in more rural and community facilities. Lastly the overall application of this study may be further limited by the very select population of AIS patients. These AIS patients must have a small core infarct and larger ischemic penumbra to gain potential benefit, all while the risk of intracerebral hemorrhage remains the same as previous studies (i.e. 5-6%).
Clinical Bottom Line:
We should no longer be using the paradigm “Time is Brain” in AIS. The advancement of neuroimaging and perfusion-based imaging in an extended stroke window is the future of stroke care by helping identify a limited population of patients that would benefit from systemic alteplase vs those with no chance to benefit at all. The difficult decision to administer systemic alteplase should be based on the individual patient’s overall clinical picture and come following an in-depth shared-decision making discussion with the patient, and/or their family, explicitly stating the benefits and risks, including those of death and further hemorrhage."