Imaging Negative Stroke: Diagnoses and Outcomes in Intravenous Tissue Plasminogen Activator–Treated Patients

Abstract

Background/Purpose Intravenous Alteplase (t-PA) improves outcome in patients with acute ischemic stroke. Of those with full recovery, some may not have had ischemia. We analyzed the frequency and post-treatment outcomes of stroke code patients with no imaging evidence of stroke in order to establish the incidence of neuroimaging negative cerebral ischemia (NNCI) and stroke mimics treated with t-PA. In addition, we compared these patients to the group of stroke patients with imaging evidence of acute stroke to determine whether there was a difference in adverse events, and functional outcomes. Methods We included all adult stroke patients treated with IV t-PA within 3 hours of stroke onset from the UCSD SPOTRIAS database through January 2013. The IPS group (Imaging Positive Stroke codes) was comprised of patients with neuroimaging evidence of acute ischemic stroke, while the INS group (Imaging Negative Stroke codes) included those patients without neuroimaging evidence of acute cerebral ischemia. All final diagnoses were reviewed by an adjudicating body. We reviewed medical records and neuroimaging; compared discharge diagnosis, 90-day mRS, and incidence of intracranial hemorrhage; and adjusted for age, admission NIHSS, pre-stroke mRS and diabetes in multivariable models. Results We identified 106 patients; 74 IPS patients and 32 INS patients, who had similar baseline characteristics, except for baseline NIHSS (IPS 12.9±8.2, INS 8.0±5.6, p=0.002) and incidence of cardiac arrhythmias (IPS 32.4%, INS 12.5%, p=0.034). The diagnoses in the INS group were stroke (23, 72%) – representing NNCI, somatization (6, 19%), tumor (1, 3%), seizure (1, 3%), and migraine (1, 3%). All IPS patients were diagnosed with acute ischemic stroke. Adjusted for age, baseline NIHSS, pre-stroke mRS and diabetes, the INS patients had significantly higher rates (OR 3.04, p=0.036) of good functional outcome (90 day mRS 0–1). ICH was found in 24% of the IPS patients and was symptomatic in 6.8%. None of the INS patients had ICH. Conclusions Since the majority of INS patients were found to have neuroimaging negative cerebral ischemia (NNCI), which may represent either TIA or aborted stroke, and there were no intracerebral hemorrhages in the INS group, our data support the safety of administering IV tissue plasminogen activator to all patients in whom acute ischemic stroke is clinically suspected. We have demonstrated that NNCI patients and stroke mimics are common and future larger scale prospective studies are required to delineate the true frequencies of each, and to evaluate differences in outcomes.

Intravenous Thrombolysis for Stroke and Presumed Stroke in Human Immunodeficiency Virus–Infected Adults

“…We report the safe use of tPA in 10 HIV patients who did not have ischemic strokes. Although other studies have reported the safe administration of IV-tPA to patients with stroke mimics,(5,6) we extend this finding to the population with potential CNS OIs. Although efficacy data were not available for the entire cohort, there was a clinically significant reduction in NIHSS score post-thrombolysis (decrement from 9 to 4 on average).…”

External validation of stroke mimic prediction scales in the emergency department

“…Negative neuroimaging for cerebral ischemia is common post thrombolysis. In well characterised thrombolysis cohorts, approximately 20% of post-thrombolysis patients [27,28] had no evidence of ischemia on follow up neuroimaging. We reported 31 (12.1%) patients with negative neuroimaging in our cohort, which is lower than published literature.…”

Defining Mild Stroke: Outcomes Analysis of Treated and Untreated Mild Stroke Patients

“…Giving a treatment with a historical 6.4% symptomatic hemorrhage in the treatment arm of the landmark study 12 seems risky when the assumed outcome of the patient in question is spontaneous recovery. It is notable that mild strokes were largely excluded from the NINDS trials 13 , and that many studies 19 - 21 have since demonstrated safety of treatment of TIAs and stroke mimics with rtPA. Our data shows a likely lower risk of ICH in our treated mild cohort, but only a prospective study comparing treated versus non-treated patients can confirm these results.…”