Ultra-Early Intravenous Stroke Thrombolysis

In acute stroke care, time is brain, and the earlier thrombolysis is given the better the final functional outcome is. Our recently published single-center analysis showed robust benefit of ultra-early compared with later thrombolysis in terms of better outcome and lower mortality, outcomes supported by the most recently published pooled analysis. In our study, we identified 10% of patients with onset-to-treatment time (OTT) within 70 minutes, whereas 29% had OTT within 90 minutes. Patients presenting with National Institutes of Health Stroke Scale (NIHSS) 7 to 12 treated within these OTT intervals had >5-fold and ≈2-fold higher likelihood of favorable outcome compared with patients treated later, respectively. Because not all patients benefit from early IV thrombolysis equally, in this study, we aimed to explore, in a large multicenter dataset, whether the extra benefit (of better outcome and lower mortality) is distributed equally among predefined Background and Purpose—We previously reported increased benefit and reduced mortality after ultra-early stroke thrombolysis in a single center. We now explored in a large multicenter cohort whether extra benefit of treatment within 90 minutes from symptom onset is uniform across predefined stroke severity subgroups, as compared with later thrombolysis. Methods—Prospectively collected data of consecutive ischemic stroke patients who received IV thrombolysis in 10 European stroke centers were merged. Logistic regression tested association between treatment delays, as well as excellent 3-month outcome (modified Rankin scale, 0–1), and mortality. The association was tested separately in tertiles of baseline National Institutes of Health Stroke Scale. Results—In the whole cohort (n=6856), shorter onset-to-treatment time as a continuous variable was significantly associated with excellent outcome (P<0.001). Every fifth patient had onset-to-treatment time≤90 minutes, and these patients had lower frequency of intracranial hemorrhage. After adjusting for age, sex, admission glucose level, and year of treatment, onset-to-treatment time≤90 minutes was associated with excellent outcome in patients with National Institutes of Health Stroke Scale 7 to 12 (odds ratio, 1.37; 95% confidence interval, 1.11–1.70; P=0.004), but not in patients with baseline National Institutes of Health Stroke Scale>12 (odds ratio, 1.00; 95% confidence interval, 0.76–1.32; P=0.99) and baseline National Institutes of Health Stroke Scale 0 to 6 (odds ratio, 1.04; 95% confidence interval, 0.78–1.39; P=0.80). In the latter, however, an independent association (odds ratio, 1.51; 95% confidence interval, 1.14–2.01; P<0.01) was found when considering modified Rankin scale 0 as outcome (to overcome the possible ceiling effect from spontaneous better prognosis of patients with mild symptoms). Ultra-early treatment was not associated with mortality. Conclusions—IV thrombolysis within 90 minutes is, compared with later thrombolysis, strongly and independently associated with excellent outcome in patients with moderate and mild stroke severity. (Stroke. 2013;44:2913-2916.)