Multi-modal Image-based Intravenous Thrombolysis In Patients With Wake-up Ischemic Stroke

Objective:To study the clinical features in wake-up ischemic stroke (WUIS) patients undergoing multimodal image-based intravenous thrombolysis and explore factors related to clinical outcomes and hemorrhagic transformation.Methods:Clinical data of WUIS patients who received multimodal image-guided intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) in our center were investigated. The data included clinical basic features, laboratory results, imaging tests, TOAST classification, hemorrhagic transformation (HT) and clinical outcomes. Multimodal images included multimodal CT and multimodal MRI. Hemorrhagic transformation (HT) was classified as hemorrhagic infarction (HI) and parenchymal hemorrhage (PH) within the first 24 hours after intravenous thrombolysis according to ECASS II criteria. Favorable outcome was defined as modified Rankin Scale (mRS) 0-2 on day 90. Factors related to hemorrhagic transformation and clinical outcomes in WUIS patients were analyzed. Univariate and binary logistic regression were analyzed to check whether different multimodal images and age were independently correlated to hemorrhagic transformation and clinical outcomes in WUIS patients, respectively.Results:A total of 650 patients received intravenous thrombolysis in our center from May 2009 to July 2015. Totally,73 patients were diagnosed as WUIS, among whom 18 patients were aged 80 or older. There were no statistically significant differences in clinical basic features, TOAST classification, hemorrhagic transformation or clinical outcome between non-wake-up ischemic stroke (NWUIS) group and WUIS group. Univariate analysis showed that WUIS patients of>80-year-old had a lower rate of male (44.4% vs 745%, p=0.018) and a higher rate of diabetes (38.9% vs 14.5%, P=0.027) as well as cardiac embolism (55.6% vs 29.1%, P=0.042) compared with those of<80-year-old WUIS patients. But there were no statistically significant differences in hemorrhagic transformation or clinical outcome between the above two groups. After adjustment, atrial fibrillation was an independently risk factor for hemorrhagic transformation (OR=7.286,95% CI 2.114～25.110, P=0.002) and baseline NIHSS was associated with neurologic outcome (OR=0.866,95% CI 0.786～0.954, P=0.004). Binary logistic regression showed that age was not an independently risk factor for hemorrhagic transformation (OR=0.683,95% CI 0.174～2.677, P=0.584) or favorable outcome (OR=0.333,95% CI 0.093～1.192, P=0.091). Meanwhile, there were no statistically significant differences in hemorrhagic transformation or clinical outcome between the multimodal CT group and multimodal MRI group in WUIS patients.Conclusions:It is feasible for WUIS patients treated by multimodal image-guided intravenous thrombolytic therapy. Age is not correlated with hemorrhagic transformation or clinical outcome in WUIS patients undergoing thrombolysis.