Abstract 2378: Right Hemisphere Ischemia is Overrepresented in Patients with Poor Outcomes After tPA is Not Given Because of “Rapidly Improving or Mild Symptoms”
Background and Purpose: Recombinant tissue-type plasminogen activator (tPA) is currently the only FDA approved treatment for acute ischemic stroke. Rapidly improving or minor symptoms is the most common reason for not treating with tPA, based on the presumption that these patients will have good outcomes without thrombolysis. We reviewed hospital course and discharge outcomes for patients excluded from tPA because of rapidly improving or mild symptoms, with the aim of being better able to identify patients in this group who may benefit from thrombolysis.
Methods: We used the AHA/ASA “Get with the Guidelines” database to identify consecutive patients between April 2006 and June 2010 from our tertiary care academic medical center who did not receive tPA with “rapidly improving or mild symptoms” indicated as the reason for exclusion. Poor outcome was defined as hospital discharge to location other than home or inability to ambulate independently at discharge. The medical record was reviewed to determine details of hospital course, infarct location, and reasons for poor outcome.
Results: There were 66 patients excluded from tPA treatment because of rapidly improving or mild symptoms. Eleven patients (16.7%) had poor outcomes. In 6 patients (9%), poor outcome was due to neurologic deficit and in 5 poor outcome was secondary to general medical conditions or deconditioning. Of the 6 patients with continued neurologic deficit, 4 were not treated due to “improvement”. All 6 patients with continued neurologic deficits had right hemisphere strokes, and one also had cerebellar infarcts.
Conclusions: Patients presenting with rapidly improving or mild symptoms do not universally have good outcomes. This may be particularly true in the case of right hemispheric ischemia where deficits are not fully reflected by NIHSS score. In conclusion, if a patient with a low NIHSS score is otherwise a candidate for tPA, a more detailed exam is warranted to better identify potentially disabling deficits that would be an indication for thrombolysis.
- © 2012 by American Heart Association, Inc.