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      Intravenous Thrombolysis in Chinese Patients with Different Subtype of Mild Stroke: Thrombolysis in Patients with Mild Stroke

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          Abstract

          Thrombolysis treatment for patients with mild stroke is controversial. The aim of our study was to investigate whether patients with mild stroke or its specific etiologic subtype might benefit from rt-PA therapy. Data were derived from two cohorts of patients with and without rt-PA treatment: (1) the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) and (2) the China National Stroke Registry (CNSR) database. Patients with mild stroke (defined as National Institutes of Health Stroke Scale ≤5) receiving the rt-PA therapy and without rt-PA therapy were matched in 1:2 for age, sex, stroke severity and etiologic subtype. A total of 134 rt-PA-treated patients were matched to 249 non-rt-PA-treated patients in the study. Among them, 104 (76%) rt-PA-treated patients with mild stroke had good outcome after 3 months compared with 173 (69.5%) non-rt-PA-treated matching cases (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.91–2.43; P = 0.12). Compared with non-rt-PA-treated group, rt-PA-treated patients had good outcome after 3 months in those with stroke subtype of large-artery atherosclerosis (LAA) (80.5% vs 65.1%; OR, 2.19; 95%CI, 1.14–4.21; P = 0.02). For patients with mild stroke, intravenous rt-PA treatment may be effective. Patients with stroke subtype of LAA might benefit more from rt-PA treatment.

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          Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies.

          P M Rothwell, Benjamin J Lovett, Brent Coull (2004)
          To study the early risk of recurrent stroke by etiologic subtype. The authors studied risk of recurrent stroke by etiologic subtype (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification) in patients in two population-based studies: the Oxford Vascular Study and the Oxfordshire Community Stroke Project. A meta-analysis was performed with data from the only two other published studies reporting equivalent data. The four studies included 1,709 strokes with 30 recurrences at 7 days, 72 at 30 days, and 113 at 3 months. Recurrent stroke risk varied between subtypes (p < 0.001). Compared with other subtypes, patients with stroke due to large-artery atherosclerosis (LAA) had the highest odds of recurrence at 7 days (odds ratio [OR] = 3.3, 95% CI = 1.5 to 7.0), 30 days (OR = 2.9, 95% CI = 1.7 to 4.9), and 3 months (OR = 2.9, 95% CI = 1.9 to 4.5). Odds of recurrence at 30 days for other subtypes were cardioembolic (OR = 1.0, 95% CI = 0.6 to 1.7), undetermined (OR = 1.0, 95% CI = 0.6 to 1.6), and small-vessel stroke (OR = 0.2, 95% CI = 0.1 to 0.6). There was no significant heterogeneity between the studies. Although only 14% of strokes were associated with LAA, this subtype accounted for 37% of recurrences within 7 days. The risk of early recurrent stroke is highest in patients with LAA. This supports the need for urgent carotid imaging and prompt endarterectomy.
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            Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator: findings from Get With The Guidelines-Stroke.

            Kimberley Reeves, Nathan Olson, Lee H. Schwamm … (2011)
            Mild or rapidly improving stroke is a frequently cited reason for not giving intravenous recombinant tissue-type plasminogen activator (rtPA), but some of these patients may have poor outcomes. We used data from a large nationwide study (Get With The Guidelines-Stroke) to determine risk factors for poor outcomes after mild or improving stroke at hospital discharge. Between 2003 and 2009, there were 29,200 ischemic stroke patients (from 1092 hospitals) arriving within 2 hours after symptom onset with mild or rapidly improving stroke symptoms as the only contraindication to rtPA. Logistic regression was used to determine the independent predictors of discharge to home. Among 93,517 patients arriving within 2 hours, 31.2% (29,200) did not receive rtPA solely because of mild/improving stroke. Among the 29,200 mild/improving cases, 28.3% were not discharged to home, and 28.5% were unable to ambulate without assistance at hospital discharge. The likelihood of home discharge was strongly related to initial National Institutes of Health Stroke Scale score (P<0.001). In multivariable-adjusted analysis, patients not discharged to home were more likely to be older, female, and black; have a higher National Institutes of Health Stroke Scale score and vascular risk factors; and were less likely to be taking lipid-lowering medication before admission. In this large, nationwide study, a sizeable minority of patients who did not receive intravenous rtPA solely because of mild/improving stroke had poor short-term outcomes, raising the possibility that stroke-related disability is relatively common, even in "mild" stroke. A controlled trial of reperfusion therapy in this population may be warranted.
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              Outcome of stroke with mild or rapidly improving symptoms.

              Jan Gralla, B Schwegler, Heinrich Mattle … (2007)
              Acute ischemic stroke with mild or rapidly improving symptoms is expected to result in good functional outcome, whether treated or not. Therefore, thrombolysis with its potential risks does not seem to be justified in such patients. However, recent studies indicate that the outcome is not invariably benign. We analyzed clinical and radiological data of patients with stroke who presented within 6 hours of stroke onset and did not receive thrombolysis because of mild or rapidly improving symptoms. Univariate and logistic regression analyses were performed to define predictors of clinical outcome. One hundred sixty-two consecutive patients (110 men and 52 women) aged 63+/-13 years were included. The median National Institutes of Health Stroke Scale score on admission was 2 (range, 1 to 14). All patients presented within 6 hours of symptom onset. After 3 months, modified Rankin Scale score was or =10 points increased the odds of unfavorable outcome or death 16.9-fold (95% CI: 1.8 to 159.5; P /=10 points, might derive a benefit from thrombolysis.
              Article 0 comments Cited 61 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Yilong Wang: yilong528@gmail.com
                Yongjun Wang: yongjunwang1962@gmail.com
                Journal
                Journal ID (nlm-ta): Sci Rep
                Journal ID (iso-abbrev): Sci Rep
                Title: Scientific Reports
                Publisher: Nature Publishing Group UK (London )
                ISSN (Electronic): 2045-2322
                Publication date (Electronic): 23 May 2017
                Publication date PMC-release: 23 May 2017
                Publication date Collection: 2017
                Volume: 7
                Electronic Location Identifier: 2299
                Affiliations
                [1 ]ISNI 0000 0004 0369 153X, GRID grid.24696.3f, Department of Neurology, Beijing Tiantan Hospital, , Capital Medical University, ; Beijing, China
                [2 ]China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
                [3 ]Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
                [4 ]Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
                [5 ]ISNI 0000 0004 0369 153X, GRID grid.24696.3f, Department of Epidemiology and Health Statistics, , School of Public Health, Capital Medical University, ; Beijing, China
                Author information
                http://orcid.org/0000-0001-8345-5147
                Article
                Publisher ID: 2579
                DOI: 10.1038/s41598-017-02579-2
                PMC ID: 5442116
                PubMed ID: 28536425
                SO-VID: aee930e6-e4d9-4d78-8f25-093b859b9107
                Copyright © © The Author(s) 2017
                License:

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 29 November 2016
                Date accepted : 13 April 2017
                Categories
                Subject: Article
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                issue-copyright-statement © The Author(s) 2017

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