Poor Outcomes in Patients Who Do Not Receive Intravenous Tissue Plasminogen Activator Because of Mild or Improving Ischemic Stroke

Abstract

Background and Purpose-Some patients with mild or improving ischemic stroke symptoms do not receive intravenous tissue plasminogen activator (tPA) because they look "too good to treat" (TGT); however, some have poor outcomes. Methods-We retrospectively analyzed data from a prospective single-center study between 2002 and 2004. TGT patients were those arriving within 3 hours of symptom onset and not treated with intravenous tPA solely because of mild or improving symptoms. Results-Of 128 patients presenting within 3 hours, 41 (34%) were not given tPA because of mild or improving stroke.Of the TGT patients, 11 of 41 (27%) died or were not discharged home because of neurological worsening (nϭ6) or persistent "mild" neurological deficit (nϭ5). No single variable at presentation was associated with death or lack of home discharge. There were 10 of 41 TGT patients (24%) who had Ն4-point improvement in National Institutes of Health Stroke Scale score before tPA decision; these patients were more likely to have subsequent neurological worsening (relative risk, 4.1, 95% CI, 1.1 to 15.4; Pϭ0.05). Conclusion-A substantial minority of patients deemed too good for intravenous tPA were unable to be discharged home.A re-evaluation of the stroke severity criteria for tPA eligibility may be indicated.

Spectacular Shrinking Deficit: Insights from Multimodal Magnetic Resonance Imaging after Embolic Middle Cerebral Artery Occlusion in Sprague—Dawley Rats

“…This seems to be of special interest given the contradicting significance attributed to brief cerebral ischemia. Whereas some studies found that transient cerebral ischemia may improve stroke outcome by serving as a preconditioning stimulus that triggers neuroprotective pathways in the brain (Castillo et al, 2003;Wegener et al, 2004), others demonstrated secondary deterioration on MRI (Fujioka et al, 1999a) or neurological function (Johnston et al, 2003;Smith et al, 2005) similar to the herein observed pathology. Hence, withholding treatment in these patients should be reconsidered and more aggressive interventions may be indicated in patients with rapidly improving symptoms, who currently are often treated with little urgency or concern (Johnston et al, 2003;Smith et al, 2005).…”

The quality of treatment of hyperacute ischemic stroke in Canada: a retrospective chart audit

“…[5][6][7][8] We found that about one-quarter of the patients who did not receive thrombolysis were noted to have neurological deficits that were too mild for treatment, which is similar to data from a 2001 study by Barber and colleagues. 18 However, about one-third of these patients will have an outcome of death or disability, 18,19 which suggests that some of these patients could have undergone treatment.…”

Why are acute ischemic stroke patients not receiving IV tPA?

“…Prior studies have found that this is the most common reason given for not treating otherwise eligible patients with IV tPA, yet multiple cohorts have found that up to one-third of patients with mild stroke symptoms at presentation will have poor long-term outcomes. [34][35][36][37] Patients with mild stroke symptoms were largely excluded from prior randomized tPA trials until the IST3 randomized controlled trial of tPA up to 6 hours from symptom onset. Subgroup analysis suggested that patients with mild stroke did not appear to benefit from treatment, although a post hoc analysis restricted to treatment within 3 hours suggested a benefit, and the most recent meta-analysis of tPA studies, including IST3, suggests a potential benefit in mild stroke.…”