Initial Stroke Severity Is the Major Outcome Predictor for Patients Who Do Not Receive Intravenous Thrombolysis due to Mild or Rapidly Improving Symptoms
Intravenous tissue plasminogen activator thrombolysis for stroke is still under use. A substantial proportion of excluded patients for mild or improving symptoms are dependent at discharge. We prospectively recruited 49 patients who did not receive thrombolysis because of mild or improving symptoms. 32 had favorable outcome (mRS ≤ 2) and 17 had unfavorable outcome (mRS > 2) at discharge. Comparisons were made between the two groups. Age was older (72.5 ± 10.0 versus 64.7 ± 13.2 years, P = 0.037), and initial National Institutes of Health Stroke Scale (NIHSS) score (5.7 ± 4.0 versus 2.2 ± 2.1, P < 0.001) was higher in the unfavorable group. Diastolic blood pressure was higher in the favorable group (98 ± 15 versus 86 ± 18 ？mmHg; P = 0.018). Atrial fibrillation (3.1 versus 23.5%; P = 0.043) and ipsilateral artery stenosis (21.9 versus 58.8%; P = 0.012) were more frequently found in the unfavorable group. Percentage of patients excluded from thrombolysis due to improving symptoms was higher in the unfavorable group (40.6 versus 82.4%; P = 0.005). Initial NIHSS score, but not other factors, was identified by logistic regression analysis as a major independent predictor for unfavorable outcome (OR 1.44; 95%CI, 1.03–2.02). 1. Introduction Patients with minor or rapidly improving neurological signs are excluded from intravenous tissue plasminogen activator (tPA) thrombolysis for acute ischemic stroke in current American Heart Association/American Stroke Association guideline [1]. A substantial proportion of patients were excluded for these reasons [2–4]. Many among those patients were significantly dependent at discharge or unable to be discharged home [2, 5]. The aim of this study was to identify predictors for unfavorable outcome in this patient group. 2. Methods Changhua Christian Hospital (CCH) is a medical center with 1.684 inpatient beds in western Taiwan, in an area with a population of 1.3 million. CCH is a participant of the nationwide Taiwan Stroke Registry (TSR) that enrolled acute stroke patients within 10 days after onset [6]. Code CCH-tPA was implemented for thrombolytic therapy in May 2008 in the hospital and activated 24 hours a day, seven days a week, at the triage by senior nursing staffs when both Cincinnati Prehospital Stroke Scale and a set of prescreen criteria are fulfilled. All patients who were excluded from intravenous thrombolysis due to mild or rapidly improving symptoms were prospectively recruited for analysis. Mild symptom was defined as National Institute of Health Stroke Scale (NIHSS) score lower than 4. Rapidly improving
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