This Article Full Text Full Text (PDF) All Versions of this Article: 36/11/2497    most recent 01.STR.0000185798.78817.f3v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smith, E. E. Articles by Schwamm, L. H. Search for Related Content PubMed PubMed Citation Articles by Smith, E. E. Articles by Schwamm, L. H. Pubmed/NCBI databases Substance via MeSH Medline Plus Health Information Stroke Related Collections Health policy and outcome research Acute Cerebral Infarction Emergency treatment of Stroke Computerized tomography and Magnetic Resonance Imaging Thrombolysis

(Stroke. 2005;36:2497.)
© 2005 American Heart Association, Inc.

Research Reports

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

Eric E. Smith, MD, FRCPC; Abdul R. Abdullah, MD; Iva Petkovska, MD; Eric Rosenthal, MD; Walter J. Koroshetz, MD Lee H. Schwamm, MD

From the Department of Neurology (E.E.S., A.R.A., W.J.K., L.H.S.), Massachusetts General Hospital, Boston; the Department of Radiological Sciences (I.P.), UCLA, Los Angeles, Calif; and the Department of Internal Medicine (E.R.), Beth Israel-Deaconess Medical Center, Boston, Mass.

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 (n=6) or persistent "mild" neurological deficit (n=5). No single variable at presentation was associated with death or lack of home discharge. There were 10 of 41 TGT patients (24%) who had 4-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; P=0.05).

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.

Key Words: angiography • computed tomography • outcome • stroke, acute • tissue plasminogen activator

This article has been cited by other articles:

				V. Puetz, I. Dzialowski, S. B. Coutts, M. D. Hill, A. Krol, C. O'Reilly, M. Goyal, A. M. Demchuk, and for the Calgary CTA Study Group Frequency and Clinical Course of Stroke and Transient Ischemic Attack Patients With Intracranial Nonocclusive Thrombus on Computed Tomographic Angiography Stroke, January 1, 2009; 40(1): 193 - 199. [Abstract] [Full Text] [PDF]

				S. Sato, K. Toyoda, T. Uehara, N. Toratani, C. Yokota, H. Moriwaki, H. Naritomi, and K. Minematsu Baseline NIH Stroke Scale Score predicting outcome in anterior and posterior circulation strokes Neurology, June 10, 2008; 70(24_Part_2): 2371 - 2377. [Abstract] [Full Text] [PDF]

				J. De Keyser, Z. Gdovinova, M. Uyttenboogaart, P. C. Vroomen, and G. J. Luijckx Intravenous Alteplase for Stroke: Beyond the Guidelines and in Particular Clinical Situations Stroke, September 1, 2007; 38(9): 2612 - 2618. [Abstract] [Full Text] [PDF]

				K. Nedeltchev, B. Schwegler, T. Haefeli, C. Brekenfeld, J. Gralla, U. Fischer, M. Arnold, L. Remonda, G. Schroth, and H. P. Mattle Outcome of Stroke With Mild or Rapidly Improving Symptoms Stroke, September 1, 2007; 38(9): 2531 - 2535. [Abstract] [Full Text] [PDF]

				M. Dirks, L. W Niessen, P. J Koudstaal, C. L Franke, R. J van Oostenbrugge, D. W J Dippel, and the members of the Delphi panel on indications and Intravenous thrombolysis in acute ischaemic stroke: from trial exclusion criteria to clinical contraindications. An international Delphi study J. Neurol. Neurosurg. Psychiatry, July 1, 2007; 78(7): 685 - 689. [Abstract] [Full Text] [PDF]

				A. Aleu, P. Mellado, C. Lichy, M. Kohrmann, and P. D. Schellinger Hemorrhagic Complications After Off-Label Thrombolysis for Ischemic Stroke Stroke, February 1, 2007; 38(2): 417 - 422. [Abstract] [Full Text] [PDF]

				S. H. Thomas, L. H. Schwamm, and M. H. Lev Case records of the Massachusetts General Hospital. Case 16-2006. A 72-year-old woman admitted to the emergency department because of a sudden change in mental status. N. Engl. J. Med., May 25, 2006; 354(21): 2263 - 2271. [Full Text] [PDF]

				C. R. Baumann, R. W. Baumgartner, J. Gandjour, H.-C. von Budingen, A. M. Siegel, and D. Georgiadis Good Outcomes in Ischemic Stroke Patients Treated With Intravenous Thrombolysis Despite Regressing Neurological Symptoms Stroke, May 1, 2006; 37(5): 1332 - 1333. [Abstract] [Full Text] [PDF]