Tolga D Dittrich, MD

European Stroke Organisation Conference
May 4-6, 2022

About one in four ischemic strokes occurs during sleep. Previous studies have shown that such patients can still benefit from IV thrombolysis with alteplase if they exhibit a DWI/FLAIR mismatch on MRI.

The randomized TWIST trial investigated the effect of IV thrombolysis with tenecteplase (0.25 mg/kg) on functional outcome in patients with wake-up stroke. Advanced neuroimaging was not required for inclusion in the trial. The key eligibility criteria were a minimum NIHSS of 3 points and a possible treatment initiation within the first 4.5 hours after awakening. The study excluded patients with high NIHSS (>25 points) and premorbid functional impairment (mRS >2).

A total of 578 patients were randomized to receive either tenecteplase or standard therapy (no IV thrombolysis). Functional outcomes at 90 days by mRS score did not differ significantly between treatment groups. Symptomatic intracranial hemorrhage was numerically more frequent in the tenecteplase group.

According to Melinda B. Roaldsen, international trial manager of TWIST, the main limitations were that the planned target sample size of 600 patients could not be reached and the more widespread use of endovascular treatment throughout the study period, which may have influenced the results.