Thrombolysis in Stroke With Unknown Onset Based on Non-Contrast Computerized Tomography (TRUST CT)

Area of Science:

• Neurology
• Emergency Medicine
• Radiology

Background:

• Advanced neuroimaging improves patient selection for intravenous thrombolysis (IVT) in wake-up stroke (WUS) or stroke with unknown onset (SUO).
• Limited availability of advanced neuroimaging in many centers necessitates alternative selection methods.
• Non-contrast computed tomography (CT) is a widely accessible imaging modality.

Purpose of the Study:

• To evaluate the feasibility and safety of non-contrast CT-based IVT in WUS/SUO patients.
• To compare outcomes of WUS/SUO patients treated with non-contrast CT-based IVT versus propensity score-matched controls.

Main Methods:

• TRUST-CT: an international multicenter registry-based study.
• Inclusion criteria: WUS/SUO patients with National Institute of Health Stroke Scale (NIHSS) ≥4 and Alberta Stroke Program Early CT Score (ASPECTS) ≥7 undergoing non-contrast CT-based IVT.
• Comparison with propensity score-matched non-thrombolyzed WUS/SUO controls.

Main Results:

• 117 IVT patients and 112 controls included; median NIHSS and ASPECTS were 10 in both groups.
• Symptomatic intracranial hemorrhage occurred in 3.4% of IVT patients vs. 0.9% of controls (aOR 7.9, P=0.1).
• Significant improvement in NIHSS (≥4 points) observed in 57.3% of IVT patients vs. 22.3% of controls (aOR 5.8, P<0.001).
• Favorable modified Rankin Scale (mRS 0-1) at 90 days in 33.3% of IVT patients vs. 20.5% of controls (aOR 1.94, P=0.05).

Conclusions:

• Non-contrast CT-based thrombolysis for WUS/SUO appears feasible and safe.
• This pragmatic approach may be effective in improving stroke outcomes.
• Randomized prospective trials are warranted to confirm these findings.