To study the safety of off-label IV thrombolysis in patients with very severe stroke (NIH Stroke Scale [NIHSS] scores >25) compared with severe stroke (NIHSS scores 15–25), where treatment is within European regulations.
Data were analyzed from 57,247 patients with acute ischemic stroke receiving IV tissue plasminogen activator in 793 hospitals participating in the Safe Implementation of Thrombolysis in Stroke (SITS) International Stroke Thrombolysis Registry (2002–2013). Eight hundred sixty-eight patients (1.5%) had NIHSS scores >25 and 19,995 (34.9%) had NIHSS scores 15–25. Outcome measures were parenchymal hemorrhage, symptomatic intracerebral hemorrhage, mortality, and functional outcome.
Parenchymal hemorrhage occurred in 10.7% vs 11.0% ( p = 0.79), symptomatic intracerebral hemorrhage per SITS-MOST (SITS–Monitoring Study) in 1.4% vs 2.5% ( p = 0.052), death at 3 months in 50.4% vs 26.9% ( p < 0.001), and functional independence at 3 months in 14.0% vs 29.0% ( p < 0.001) of patients with NIHSS scores >25 and NIHSS scores 15–25, respectively. Multivariate adjustment did not change findings from univariate comparisons. Posterior circulation stroke was more common in patients with NIHSS scores >25 (36.2% vs 7.4%, p < 0.001), who were also more often obtunded or comatose on presentation (58.4% vs 7.1%, p < 0.001). Of patients with NIHSS scores >25, 26.2% were treated >3 hours from symptom onset vs 14.5% with NIHSS scores of 15–25.
Our data show no excess risk of cerebral hemorrhage in patients with NIHSS score >25 compared to score 15–25, suggesting that the European contraindication to IV tissue plasminogen activator treatment at NIHSS levels >25 may be unwarranted. Increased mortality and lower rates of functional independence in patients with NIHSS score >25 are explained by higher stroke severity, impaired consciousness on presentation due to posterior circulation ischemia, and longer treatment delays.
Commercial: Speaker' honoraria and travel support from Boehringer-Ingelheim, Lundbeck, Ferrer
Boehringer-Ingelheim, one of the sponsors of the SITS registry would potentially benefit from the conclusions of the study
The SITS registry recieves or received financial support from Boehringer-Ingelheim, Ferrer,
The SITS registry recieves or received financial support from Swedish government (Vinnova), EU FP7, EU Public Health authority, Stockholm county council
I am an employee of SITS International, which received grant from Boehringer-Ingelheim and Ferrer
I am an employee of SITS International, which received grant from European Union Public Health Executive Authority (PHEA). Financial support was also provided through the regional agreement on medical training and research (ALF) between Stockholm County Council and the Karolinska Institute. This study is a part of the Fighting Stroke Project (Uppdrag Besegra Stroke), supported by the Swedish Heart and Lung Foundation, Karolinska Institutet, Friends of Karolinska Institutet, USA, and Johanniterorden (Swedish Order of St. John).
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