Thrombolytic Therapy in Extended Window with only Non-contrast Computed Tomography: A Systematic Review and Meta-analysis
Juan Oyola1, Juan Martinez Lemus2, Victória Siebel3, Claudio Monsalve1, Hernan Bayona1
1Hospital Simón Bolívar, Departamento de Neurología, Subred Integrada de Servicios de Salud Norte ESE, Bogotá., 2UTHealth Houston, McGovern Medical School, Houston, TX, United States of America, 3Universidad de Aquino, Bolivia
Objective:
This study aimed to comprehensively review and analyze clinical trials and observational studies regarding Thrombolytic Therapy for Acute Ischemic Stroke (AIS) in an extended window using only Non-Contrast Computed Tomography (NCCT).
Background:
Recently, Thrombolytic Therapy has been proposed as an effective and safe measure for patients who arrive beyond the 4.5 hours of symptoms onset, Wake Up Stroke (WUS), or with unknown onset of symptoms (UOS), improving functional outcomes without increasing mortality in this population, when selected with perfusion imaging. However, these imaging modalities are often not available in low-resource settings.
Design/Methods:
We conducted a systematic review of PubMed, Embase, Wiley Online, and Web of Science, searching for either Clinical Trials or Observational studies that compared Thrombolytic Therapy against standard care in patients with AIS arriving beyond 4.5 hours of Symptoms, WUS, or UOS using only NCCT. P value was significant at 0.05. Stata SE. 18.0 was used for statistical analysis.
Results:
From 874 records, 11 studies met inclusion criteria for the systematic review. Three studies compared IVT versus standard care in the extended window, and were eligible for meta-analysis. For functional independence (modified Rankin score 0-2), it resulted in a pooled odds ratio of 0.16 (95% CI: 0.07–0.38; I² = 92.8%, τ² = 0.04, p-value = 0.170, n = 1349), favoring thrombolysis. Moreover, there is no statistically significant increase in intracranial hemorrhage with treatment compared to control (OR = 0.02, 95% CI: 0.00 - 0.03, I² = 0.0%, τ² = 0.00, p-value = 0.070, n = 876).
Conclusions:
Thrombolysis guided by NCCT in the extended window appears potentially effective and safe. These findings may help expand access to thrombolytic therapy in low-resource settings and should be evaluated in larger, prospective trials.
Keywords: Acute Ischemic Stroke, Thrombolytic Therapy, Extended Window, Wake Up Stroke, Stroke of Unknown Onset, Non-Contrast Computed Tomography
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