Predictors of major neurological improvement after intravenous thrombolysis in acute ischemic stroke: A hospital-based study from south India

Boddu, Demudu Babu; Bandaru, V C S Srinivasarao; Reddy, Prasad G; Madhusudan, M. D.; Rukmini, M.; Turaga, Suryaprabha; Jabeen, Shaik Afshan; Suvarna, A.; Jayalakshmi, Sita; Meena, A K; Borgohain, Rupam; Kaul, Subhash

doi:10.4103/0028-3886.66085

Cited by 18 publications

(17 citation statements)

References 9 publications

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“…Most studies that have examined early response to tPA focused on clinical findings 24 hours after stroke. 7 In clinical practice, however, decisions regarding additional therapies after stroke must be made within minutes to a few hours when additional neuroprotection or tissue salvage is still possible. 8 …”

Section: Discussionmentioning

confidence: 99%

Two-Hour Improvement of Patients in the National Institute of Neurological Disorders and Stroke Trials and Prediction of Final Outcome

Hemmen

Ernström

Raman

2011

Stroke

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Background Ongoing clinical trials are using early response to IV tPA to stratify patients into endovascular therapies. Little is known about the likelihood of early recovery and its correlation with final stroke outcome. Methods We analyzed the NINDS t-PA dataset for patients with early improvement (EI), a change of ≥4 or score 0 on the 2-hour NIHSS, to predict good 90-day outcome. We adjusted for multiple confounders and divided the patients by baseline NIHSS 0–10, 11–20, >20 and stroke type to analyze if EI predicted good outcome across stroke severities and types. We analyzed different EI thresholds to identify the best level of NIHSS change to predict good 90-day outcome using a Receiver Operator Characteristic (ROC). Results In total 183/624 (29.3%) patients had EI, 112/312 (35.9%) in the tPA and 71/312 (22.7%) in the placebo groups (p<0.0001). Smokers (p=0.012) and patients treated under 90 minutes (p=0.008) were more likely; diabetics (p=0.023) less likely to show EI. The baseline NIHSS (mean±SD) of patients with EI was 16.1±6.5 versus 14.3±7.4 (p=0.001). A 90-day mRS of 0–1 was achieved in 68/112 (60.7%) tPA treated patient with EI and 65/200 (32.5%) without (placebo groups 30/71 (42.3%) versus 53/241 (22.0%)). The adjusted odds ratio for good outcome was 1.71 (95% CI: 1.1,2.6, p=0.011) for t-PA treatment and 7.69 (4.63, 12.76, p<0.0001) for early improvement. EI predicted good outcome in patients with cardioembolic (13.6(3.6–51.5)) and small vessel (6.98(2.86–17.03), but not large vessel stroke (1.82(0.38–8.59). The ROC showed that a threshold of 4 on the NIHSS for prediction of good outcome had a sensitivity of 84% and 36% specificity. Conclusion Early improvement was more common in t-PA treated patients and associated with good 90 day outcome. While 32.5% of non-responders after t-PA had a good 90 day outcome, the use of EI to predict stroke outcome shows value.

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Section: Discussionmentioning

confidence: 99%

Two-Hour Improvement of Patients in the National Institute of Neurological Disorders and Stroke Trials and Prediction of Final Outcome

Hemmen

Ernström

Raman

2011

Stroke

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“…A subset of patients treated with IV tPA have a significant recovery, shedding a substantial component of their neurological deficit within 24 hours [6][7][8][9][10][11][12]14]. This phenomenon has been documented in a number of studies, and has been labelled under a wide array of names including "rapid neurological recovery", "early neurological improvement", "major neurological improvement", "dramatic recovery" and the "Lazarus phenomenon".…”

Section: Rapid Neurological Recovery: Definitions Incidence and Outcomementioning

confidence: 99%

“…Despite the differing labels and definitions, the inci-dence and outcomes of rapid neurological recovery have been reported consistently across the literature. Studies showed that between 18% -33% of patients treated with IV tPA experienced some form of early recovery [6][7][8][9]11,12,14]. Furthermore, patients with rapid neurological recovery have lower 30 day mortality and are far more likely to have a favourable functional outcome (modified Rankin Score of 0 or 1) at 3months than patients without early recovery [6][7][8][9][10]14].…”

Section: Rapid Neurological Recovery: Definitions Incidence and Outcomementioning

confidence: 99%

“…Rapid Neurological Recovery Drop in NIHSS by 50% or more within 24 hours [7] Lazarus Phenomenon Drop in NIHSS by 50% or more within 24 hours [29] Dramatic Recovery Drop in NIHSS by 10 points or more OR Drop of NIHSS to 3 points or less during infusion [14] Early Dramatic improvement Drop in NIHSS by 10 points or more OR Drop of NIHSS to 2 points or less, within 24 hours [30] Major Neurological Improvement Drop in NIHSS by 8 points or more OR NIHSS of 0 points at 24 hours [6] Major Neurological Recovery Drop in NIHSS by 8 points or more OR NIHSS of 0 or 1 at 24 hours [9,12] Dramatic Recovery Drop of NIHSS to 2 points or less after infusion [31] Early Improvement Drop of NIHSS to 4 points or less at 24 hours [8] Very Early Neurological Improvement NIHSS of 0 or improvement of 5 or more by end of infusion [11] Conversely, in the cohort without early reperfusion only 19% showed a good functional outcome, a finding mirrored in numerous studies [31,32]. As recovery is strongly associated with vessel recanalization, it stands to reason that early recovery is likely a consequence of early recanalization.…”

Section: Labels Definitionsmentioning

confidence: 99%

“…Various studies including the pivotal NINDS and ECASS trials have shown that IV tPA reduces long term disability and improves function [1,2,4]. A proportion of patients treated with IV tPA experience a phenomenon termed rapid neurological recovery [6][7][8][9][10][11][12]. It has been shown that early recovery correlates with a more favourable long term prognosis [6][7][8][9][10][11][12][13].…”

Section: Introductionmentioning

confidence: 99%

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Rapid Neurological Recovery Post Thrombolysis: Mechanisms and Implications

Machumpurath¹,

Reddy²,

Yan³

2013

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Intravenous thrombolysis improves long term functional outcomes in acute ischemic stroke. A select proportion of patients treated with thrombolysis experience rapid early neurological recovery, a powerful predictor of favourable long term outcomes. There is increased interest to augment early neurological recovery by endovascular therapy or by adjuvant intravenous thrombolytics. However, incomplete understanding of the physiological mechanisms of early recovery has hampered a unified approach to monitor and to triage patients for invasive therapy. This review aims to examine the current understanding and insights gained from recent studies concerning early recovery and to inform the design of future studies.

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Intravenous thrombolysis for acute cerebral ischaemia in old stroke patients ≥80 years of age

Boulouis¹,

Dumont²,

Cordonnier³

et al. 2011

J Neurol

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Despite increasing life expectancy, few data exist on the outcome of elderly stroke patients treated with IV thrombolysis. We analyzed the prospectively collected data from the Lille University Hospital stroke unit on patients treated with IV rt-PA within 4.5 h, comparing patients ≥80 years to younger ones. We considered the following outcomes: neurological improvement at the acute phase (NIHSS 0 or 1 at 24 h, or if the difference between NIHSS at 24 h and at baseline was ≥4), occurrence of intracerebral haemorrhage, mortality and functional outcome in survivors (favourable if mRS ≤2 or equal to pre-stroke score) at 3 months. Predictors of vital and functional outcome were determined using logistic regression analysis. Four hundred patients were treated with IV rt-PA, 98 (25%) being ≥80 years. The proportion of patients with neurological improvement at the acute phase (31 vs. 40%, OR 0.7, 95%CI 0.4-1.2), and with ICH (19 vs. 21%, OR 0.9, 95%CI 0.5-1.7) was similar among older and younger patients. At 3 months, 35% of patients ≥80 years had died; 52% of survivors had favourable functional outcome. Using multivariate analysis, age ≥80 years was an independent predictor of death (3.4; 95%CI 1.6-7.3), and of reduced likelihood of favourable functional outcome in survivors (OR 0.3; 95%CI 0.2-0.7) at 3 months. Although outcome at 3 months is worse for older patients than for their younger counterparts, our results are encouraging with a similar proportion of patients with early neurological improvement and with ICH in old and young patients and about half of the survivors having a favourable functional outcome in patients ≥80 years.

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Predictors of major neurological improvement after intravenous thrombolysis in acute ischemic stroke: A hospital-based study from south India

Cited by 18 publications

References 9 publications

Two-Hour Improvement of Patients in the National Institute of Neurological Disorders and Stroke Trials and Prediction of Final Outcome

Two-Hour Improvement of Patients in the National Institute of Neurological Disorders and Stroke Trials and Prediction of Final Outcome

Rapid Neurological Recovery Post Thrombolysis: Mechanisms and Implications

Intravenous thrombolysis for acute cerebral ischaemia in old stroke patients ≥80 years of age

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