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Updated: May 29, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
MRI-based intravenous thrombolysis in stroke patients with unknown time of symptom onset
M Ebinger1, J F Scheitz, A Kufner
1Center for Stroke Research Berlin (CSB), Charitéplatz, Berlin, Germany. martin.ebinger@charite.de
Background:
Currently, stroke patients with unknown time of symptom onset (UTOS) are excluded from therapy with intravenous tissue Plasminogen Activator. We hypothesized that MRI-based intravenous thrombolysis is safe in UTOS.
Methods:
We analyzed radiological and clinical data as well as outcomes of stroke patients (including UTOS) who received intravenous thrombolytic therapy after MRI.
Results:
Compared to patients with known time of symptom onset (n=131), UTOS (n=17) were older (81, 71-88 vs. 75 years, 66-82, P=0.03), had a longer median time between last-seen-well and thrombolysis (12.3 h, IQR 11.5-15.2 h vs. 2.1 h, 1.8-2.8 h, P<0.01), had a longer median door-to-needle time (86 min, 49-112 vs. 60 min, 49-76, P=0.02), and a higher rate of arterial obstruction on MR-angiography (82.4% vs. 56.5%, P=0.04). No symptomatic intracerebral hemorrhage occurred in UTOS. After 3 months, there was no significant difference between groups concerning good functional outcome (modified Rankin Scale 0-2; 35.3% vs. 49.6%, P=0.26) or mortality (0% vs. 15.3%, P=0.08). In multivariate analyses including age, gender, baseline NIHSS, and atrial fibrillation UTOS did not have an independent effect on good functional outcome after 3 months (OR 1.16; 0.32-4.12, P=0.81).
Conclusions:
Thrombolysis after MRI seems safe and effective in UTOS. This observation may encourage those who plan prospective placebo-controlled trials of thrombolytics in this subgroup of stroke patients.
Insights
MRI-guided thrombolysis is safe and effective for stroke patients with unknown time of symptom onset (UTOS). This approach expands treatment eligibility, offering hope for better outcomes in this previously excluded group.
Area of Science:
- Neurology
- Radiology
- Emergency Medicine
Background:
- Stroke patients with unknown time of symptom onset (UTOS) are typically excluded from intravenous thrombolysis.
- Intravenous tissue Plasminogen Activator (tPA) is the standard therapy, but its use is time-sensitive.
- Hypothesis: MRI-guided thrombolysis is a safe and effective option for UTOS patients.
Purpose of the Study:
- To evaluate the safety and efficacy of MRI-guided intravenous thrombolysis in stroke patients with UTOS.
- To compare outcomes of UTOS patients receiving thrombolysis with those with a known time of symptom onset.
Main Methods:
- Retrospective analysis of radiological and clinical data of stroke patients who underwent MRI-guided thrombolysis.
- Comparison of outcomes between UTOS patients and patients with known symptom onset times.
- Assessment of symptomatic intracerebral hemorrhage, functional outcome (modified Rankin Scale), and mortality at 3 months.
Main Results:
- UTOS patients (n=17) were older and had longer times from last-seen-well to thrombolysis and door-to-needle times compared to controls (n=131).
- A higher rate of arterial obstruction was observed in UTOS patients on MR-angiography.
- No symptomatic intracerebral hemorrhage occurred in the UTOS group; functional outcomes and mortality were not significantly different at 3 months.
Conclusions:
- MRI-guided thrombolysis appears safe and effective in stroke patients with UTOS.
- These findings support the potential for prospective trials investigating thrombolytics in the UTOS subgroup.
- This approach could expand treatment options for stroke patients previously ineligible for therapy.
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