(Medscape excerpts)
Using perfusion imaging to
identify patients with salvageable brain tissue following ischemic stroke is
the key to extending the window for thrombolysis out to 9 hours.
The results of the EXTEND
trial show that more patients presenting between 4.5 and 9 hours treated with
tPA (alteplase) under these conditions achieved a score of 0 or 1 on the
modified Rankin scale (indicating no deficits or minimal deficits,
respectively) than those give placebo.
The EXTEND trial is published
in the May 9 issue of The New England Journal of Medicine. The results were
first presented at the International Stroke Conference (ISC) in Hawaii earlier
this year.
These results open up the
possibility of treating many more stroke patients with thrombolysis.
The study is positive and
provides level 1 evidence for tPA out to 9 hours (including wake-up strokes) in
patients with suitable imaging showing that brain tissue is salvageable.
There have been two previous
studies looking at late tPA with a similar design — ECASS-4 and EPITHET, and a
meta-analysis of all three trials is about to be presented at this month's
European Stroke Organisation Conference (ESOC) meeting in Milan, Italy.
225 patients with ischemic
stroke who had hypoperfused but salvageable regions of brain detected on
automated perfusion imaging were randomly assigned to receive intravenous
alteplase or placebo between 4.5 and 9 hours after the onset of stroke or on
awakening with stroke (if within 9 hours from the midpoint of sleep).
The primary outcome (a score
of 0 or 1 on the modified Rankin scale at 90 days) occurred in 40 patients
(35.4%) in the alteplase group and in 33 patients (29.5%) in the placebo group.
Symptomatic intracerebral
hemorrhage occurred in 7 patients (6.2%) in the alteplase group and in 1
patient (0.9%) in the placebo group.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical
Associations in Asia and Oceania
(CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of
India
Past National President
IMA
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