Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data

Background: Patients who have had a stroke with unknown time of onset have been previously excluded from thrombolysis. We aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers. Methods: We did a systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020. Randomised trials of intravenous alteplase versus standard of care or placebo in adults with stroke with unknown time of onset with perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch were eligible. The primary outcome was favourable functional outcome (score of 0–1 on the modified Rankin Scale [mRS]) at 90 days indicating no disability using an unconditional mixed-effect logistic-regression model fitted to estimate the treatment effect. Secondary outcomes were mRS shift towards a better functional outcome and independent outcome (mRS 0–2) at 90 days. Safety outcomes included death, severe disability or death (mRS score 4–6), and symptomatic intracranial haemorrhage. This study is registered with PROSPERO, CRD42020166903. Findings: Of 249 identified abstracts, four trials met our eligibility criteria for inclusion: WAKE-UP, EXTEND, THAWS, and ECASS-4. The four trials provided individual patient data for 843 individuals, of whom 429 (51%) were assigned to alteplase and 414 (49%) to placebo or standard care. A favourable outcome occurred in 199 (47%) of 420 patients with alteplase and in 160 (39%) of 409 patients among controls (adjusted odds ratio [OR] 1·49 [95% CI 1·10–2·03]; p=0·011), with low heterogeneity across studies (I2=27%). Alteplase was associated with a significant shift towards better functional outcome (adjusted common OR 1·38 [95% CI 1·05–1·80]; p=0·019), and a higher odds of independent outcome (adjusted OR 1·50 [1·06–2·12]; p=0·022). In the alteplase group, 90 (21%) patients were severely disabled or died (mRS score 4–6), compared with 102 (25%) patients in the control group (adjusted OR 0·76 [0·52–1·11]; p=0·15). 27 (6%) patients died in the alteplase group and 14 (3%) patients died among controls (adjusted OR 2·06 [1·03–4·09]; p=0·040). The prevalence of symptomatic intracranial haemorrhage was higher in the alteplase group than among controls (11 [3%] vs two [<1%], adjusted OR 5·58 [1·22–25·50]; p=0·024). Interpretation: In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death. Funding: None

A time-resolved proteomic and prognostic map of COVID-19

COVID-19 is highly variable in its clinical presentation, ranging from asymptomatic infection to severe organ damage and death. We characterized the time-dependent progression of the disease in 139 COVID-19 inpatients by measuring 86 accredited diagnostic parameters, such as blood cell counts and enzyme activities, as well as untargeted plasma proteomes at 687 sampling points. We report an initial spike in a systemic inflammatory response, which is gradually alleviated and followed by a protein signature indicative of tissue repair, metabolic reconstitution, and immunomodulation. We identify prognostic marker signatures for devising risk-adapted treatment strategies and use machine learning to classify therapeutic needs. We show that the machine learning models based on the proteome are transferable to an independent cohort. Our study presents a map linking routinely used clinical diagnostic parameters to plasma proteomes and their dynamics in an infectious disease

HDV-genotype distribution in Vietnamese HBsAg-positive patients.

<p>(<b>A</b>) Representative HDV sequences of the HBsAg-positive patients aligned with HDV reference sequence NC001653. HDV sequences spanning the region from nt 335 to nt 635 showing patient-specific HDV isolates. (<b>B</b>) Phylogenetic analysis inferred from distance analysis (Kimura 2 parameters model) and neighbor-joining reconstruction from HDV-sequences (nt 888 to nt 1122) of the Vietnamese HDV isolates and the corresponding region of the reference sequences showing that the Vietnamese HDV isolates clustered mainly in the Asian HDV-genotype 1 branch and two isolates (C03 and C06) in the HDV-genotype 2 branch. Vietnamese HDV sequences are referred to as “letter/number”, i.e., “B127”. The Vietnamese HDV sequences were compared to HDV reference sequences, gathering the 8 HDV genotypes which are denoted at the right in brackets (NCBI-Genbank accession numbers are denoted in the figure). The numbers at the nodes indicate bootstrapping values. The bar represents nucleotide substitutions per position.</p

HBV replication of different HBV-genotypes in HBV/HDV coinfection.

<p>(<b>A</b>) Determination of HBV loads of the predominant HBV-genotype A and HBV-genotype C samples in the Vietnamese HDV-positive patients (*denotes p<0.05). (<b>B</b>) Comparison of HBV loads in the HBV-genotype A samples according to the status of HDV-coinfection. The HBV load was closely significantly lower in HDV-positive patients than HDV-negative patients (p = 0.053). p<0.05 is statistically significant.</p

Prevalence of HDV genomes in the HBsAg-positive Vietnamese patients.

<p>The prevalence of HDV infection in AHB group was significantly higher in comparison to the CHB, LC and HCC groups (OR =0.19 (CI95 [0.23-0.66]), 0.20 (CI95 [0.08-0.54]), 0.25 (CI95 [0.22-0.71]), respectively; two tailed Fisher’s exact test, p<0.01). Overall, the HDV-prevalence of all patient groups was 15.4% (CI95 [11.1-19.8]) (Total). </p

Strategy of primer design and RT-PCR schema.

<p>(<b>A</b>) Primer design for HDV-specific nested RT-PCR located in a highly conserved region of the HDV genome. HDV-specific primers HDV-04 and HDV-05 for the first PCR round, HDV-06 and HDV-07 for the nested PCR were designed for HDV detection and genotyping. The primers were matched and aligned with 38 reference sequences of the eight HDV genotypes available in the NCBI-GenBank. The primer sequences target to the ribozyme and HDAg domains of the HDV genome. The numbers 1 to 8 of each reference sequence code for the respective HDV-genotype. R1, R2 = ribozyme domain; C = C-terminal amino acid extension. HDAg: Hepatitis Delta antigen; position marked at nt 1015 indicates RNA editing site. (<b>B</b>) Schematic representation of primer binding sites. The primers HDV-06 and HDV-07 of the nested PCR used for HDV detection and HDV-genotyping span the region from nt 888 to nt 1122. The HDV-fragment from the position nt 316 to nt 691 is generated by the primer pair HDV-19 and HDV-20. Numbering is according to HDV strain NC1001653. (<b>C</b>) Representative example of 1.5% agarose gelelectrophoresis of amplified HDV products. HDV specific nRT-PCR amplicons of 235 bp are shown. HDV positive samples could be identified in lanes 3, 5, 13, 14, 22, 30, and 32. Positive control (PC) was a HDV full-length plasmid. NC = negative control. Marker (M) is 100bp DNA ladder. </p

A time-resolved proteomic and prognostic map of COVID-19

COVID-19 is highly variable in its clinical presentation, ranging from asymptomatic infection to severe organ damage and death. We characterized the time-dependent progression of the disease in 139 COVID-19 inpatients by measuring 86 accredited diagnostic parameters, such as blood cell counts and enzyme activities, as well as untargeted plasma proteomes at 687 sampling points. We report an initial spike in a systemic inflammatory response, which is gradually alleviated and followed by a protein signature indicative of tissue repair, metabolic reconstitution, and immunomodulation. We identify prognostic marker signatures for devising risk-adapted treatment strategies and use machine learning to classify therapeutic needs. We show that the machine learning models based on the proteome are transferable to an independent cohort. Our study presents a map linking routinely used clinical diagnostic parameters to plasma proteomes and their dynamics in an infectious disease

Functional Outcome of Intravenous Thrombolysis in Patients With Lacunar Infarcts in the WAKE-UP Trial

Importance: The rationale for intravenous thrombolysis in patients with lacunar infarcts is debated, since it is hypothesized that the microvascular occlusion underlying lacunar infarcts might not be susceptible to pharmacological reperfusion treatment. Objective: To study the efficacy and safety of intravenous thrombolysis among patients with lacunar infarcts. Design, Setting, and Participants: This exploratory secondary post hoc analysis of the WAKE-UP trial included patients who were screened and enrolled between September 2012 and June 2017 (with final follow-up in September 2017). The WAKE-UP trial was a multicenter, double-blind, placebo-controlled randomized clinical trial to study the efficacy and safety of intravenous thrombolysis with alteplase in patients with an acute stroke of unknown onset time, guided by magnetic resonance imaging. All 503 patients randomized in the WAKE-UP trial were reviewed for lacunar infarcts. Diagnosis of lacunar infarcts was based on magnetic resonance imaging and made by consensus of 2 independent investigators blinded to clinical information. Main Outcomes and Measures: The primary efficacy variable was favorable outcome defined by a score of 0 to 1 on the modified Rankin Scale at 90 days after stroke, adjusted for age and severity of symptoms. Results: Of the 503 patients randomized in the WAKE-UP trial, 108 patients (including 74 men [68.5%]) had imaging-defined lacunar infarcts, whereas 395 patients (including 251 men [63.5%]) had nonlacunar infarcts. Patients with lacunar infarcts were younger than patients with nonlacunar infarcts (mean age [SD], 63 [12] years vs 66 [12] years; P = .003). Of patients with lacunar infarcts, 55 (50.9%) were assigned to treatment with alteplase and 53 (49.1%) to receive placebo. Treatment with alteplase was associated with higher odds of favorable outcome, with no heterogeneity of treatment outcome between lacunar and nonlacunar stroke subtypes. In patients with lacunar strokes, a favorable outcome was observed in 31 of 53 patients (59%) in the alteplase group compared with 24 of 52 patients (46%) in the placebo group (adjusted odds ratio [aOR], 1.67 [95% CI, 0.77-3.64]). There was 1 death and 1 symptomatic intracranial hemorrhage according to Safe Implementation of Thrombolysis in Stroke-Monitoring Study criteria in the alteplase group, while no death and no symptomatic intracranial hemorrhage occurred in the placebo group. The distribution of the modified Rankin Scale scores 90 days after stroke also showed a nonsignificant shift toward better outcomes in patients with lacunar infarcts treated with alteplase, with an adjusted common odds ratio of 1.94 (95% CI, 0.95-3.93). Conclusions and Relevance: While the WAKE-UP trial was not powered to demonstrate the efficacy of treatment in subgroups of patients, the results indicate that the association of intravenous alteplase with functional outcome does not differ in patients with imaging-defined lacunar infarcts compared with those experiencing other stroke subtypes