Abstract 28: “Defining The Undefined”- Rapidly Improving Stroke Symptoms: A Systematic Review of the Literature.
Background: “Rapidly Improving Stroke Symptoms” (RISS) is a major exclusion criterion for tPA treatment in acute ischemic stroke (AIS).
Objectives: To explore various definitions used for RISS and reported clinical outcomes of RISS patients, treated and untreated with tPA.
Methods: A systematic review of the literature(through Aug 5, 2013)for studies reporting definition or outcome data for RISS or both, was performed by 3 independent reviewers using prespecified medical subjects heading (MeSH) terms, Boolean logic and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.
Results: From 97 potentially eligible articles identified via abstract review, 35 were excluded for inadequate data. Of the 62 articles remaining: 38 did not provide definitions for RISS; 9 reported data of RISS with minor stroke together while 15 considered them separately and reported 5 different definitions of RISS: 1) physician judgment (n=9); 2) ≥4 point reduction in NIHSS score from initial to tPA decision time (n=3); 3) general impression of significant improvement before tPA(n=1); 4)major symptoms rapidly improving by the time of decision (n=1); 5) documented significant improvement in at least 4of the following items - motor paresis of arm, - leg or - facial muscles, - aphasia - dysarthria and - sensory deficit - (n=1). RISS outcome data was reported separately from minor stroke in 5/62 (8%) studies: 1) favorable outcome (mRS=0-1, NIHSS= 0-1) at 3 months were reported in 15/19 (78%) of RISS patients given tPA; 2) 25/57 (44%) of RISS patients were dependent/died at discharge; 3)13/27 (48%) of RISS had favorable outcome; 4) 4/10 (40%) RISS patients were discharged home; RISS patients were more likely than non-RISS to have large-artery occlusion (5/10 versus 3/31; P=0.01); 5)In 39 RISS patients there was an association between NIHSS ≥10 and unfavorable outcome at 3 months (p=0.026).
Conclusions: There is no generally accepted definition for RISS and in most cases it is left to the physician’s judgment, which varies. A high proportion of AIS patients excluded from tPA solely because of RISS have poor outcome. Future research needs to validate RISS definitions and determine how different definitions predict clinical outcome.
Author Disclosures: P. Piran: None. C. Balucani: None. C. Ramkishun: None. S. Tariq: None. Y.S. Lederman: None. B.E. Tark: None. S.R. Levine: None.
- © 2014 by American Heart Association, Inc.