Yasmin Aziz, MD
International Stroke Conference 2021
March 17–19, 2021
Session: Mismatch Misalignments for Extended-window IV-thrombolysis for Non-Large Vessel Occlusion Strokes (Debate)
Moderator: Dr. Gotz Thomalla
Can thrombolytics be given safely and efficaciously beyond 4.5 hours? That was the debate topic for one of ISC’s first live debates to kick off Wednesday morning.
Dr. Shlee Song: DWI-FLAIR Mismatch Rules!
The arguments began with Dr. Song, who focused on DWI-FLAIR mismatch. After a brief introduction with the MR WITNESS trial results, she then discussed how patients with DWI-FLAIR mismatch treated with alteplase had better outcomes at 90 days in the WAKE UP study. She also made the point that while efficient MRI scanning of acute stroke patients can be cumbersome, in addition to treating more patients, we can also avoid potential side effects of treating with conventional CT/CTA methods (i.e., contrast nephropathy and ICH in the event of unseen microhemorrhages only visible on MR).
Dr. Henry Ma: Core-Penumbra Mismatch Rules!
Dr. Ma followed suit with Dr. Song’s sentiment of treating with alteplase in the extended time window, focusing on patients with core-penumbra mismatch as a potential enriched cohort, that may satisfy an optimal risk/benefit ratio to late lytic administration. Focusing on the EPITHET and EXTEND studies, he stated that patients in multiple extended time windows who underwent automated perfusion imaging in addition to standard CTH/CTA imaging not only showed similar risks/benefits to conventional time window treatment with alteplase, including risk of ICH and overall mortality.
Dr. Bruce Campbell: All Aboard for Extended-Window tPA!
Dr. Campbell was next on the virtual debate stage. He focused primarily on meta-analyses of the EXTEND, EPITHET, and ECASS4 trials, showing clear benefit of alteplase reperfusion at all timepoints in patients with automated perfusion-mismatch imaging. He also noted that the prospect of additionally adding thrombolytics in the extended window combined with endovascular therapy has yet to be determined.
Dr. Mark Alberts: Hold the Train! No Extended Window tPA!
Finally, Dr. Alberts concluded the debate with a lively talk, in which he was against giving alteplase in the extended time window. Overall, he noted that limitations of alteplase in the extended time window are multiple, including: small trials that were stopped early, increased ICH and death, low NIHSS on average with potential bias towards good outcome, and inconsistent efficacy.
At the conclusion of the debate, a live audience poll showed that 77% of viewers would consider administration of lytics in the extended time window, while 23% would not.