ABSTRACT
OBJECTIVE: There are limited data on which patients not treated with intravenous (IV) tissue-type plasminogen activator (tPA) due to mild and rapidly improving stroke symptoms (MaRISS) have unfavorable outcomes. MATERIALS AND METHODS: Acute ischemic stroke (AIS) patients not treated with IV tPA due to MaRISS from January 1, 2009 to December 31, 2013 were identified as part of the Georgia Coverdell Acute Stroke Registry. Multivariable regression analysis was used to identify factors associated with a lower likelihood of favorable outcome, defined as discharge to home. RESULTS: There were 1614 AIS patients who did not receive IV tPA due to MaRISS (median National Institutes of Health stroke scale [NIHSS] 1], of which 305 (19%) did not have a favorable outcome. Factors associated with lower likelihood of favorable outcome included Medicare insurance status (odds ratio [OR]: .53, 95% confidence interval [CI]: .34-.84), arrival by emergency medical services (OR: .46, 95% CI: .29-.73), increasing NIHSS score (per unit OR: .89, 95% CI: .84-.93), weakness as the presenting symptom (OR: .50, 95% CI: .30-.84), and a failed dysphagia screen (OR: .43, 95% CI: .23-.80). During the study period, <1% of patients presenting to participating hospitals with MaRISS within the eligible time window received IV tPA. CONCLUSIONS: Baseline characteristics, presenting symptoms, and response to dysphagia screen identify a subgroup of patients who are more likely to have an unfavorable outcome. Whether IV tPA treatment can improve the outcome in this subgroup of patients needs to be evaluated in a randomized placebo-controlled trial.
Subject(s)
Brain Ischemia/complications , Deglutition Disorders/etiology , Deglutition , Stroke/complications , Aged , Brain Ischemia/diagnosis , Brain Ischemia/physiopathology , Brain Ischemia/therapy , Deglutition Disorders/diagnosis , Deglutition Disorders/physiopathology , Deglutition Disorders/therapy , Disability Evaluation , Female , Georgia , Humans , Male , Middle Aged , Multivariate Analysis , Odds Ratio , Patient Discharge , Predictive Value of Tests , Registries , Risk Factors , Severity of Illness Index , Stroke/diagnosis , Stroke/physiopathology , Stroke/therapy , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: Ischemic stroke patients benefit most from intravenous thrombolysis when they receive the treatment as quickly as possible after symptom onset. Hospitals participating in the Georgia Coverdell Acute Stroke Registry reduced the time from patient arrival to administration of intravenous tissue plasminogen activator. This study evaluates the benefit of reducing door-to-treatment (DTT) time as measured by hospital length of stay (LOS). METHODS: Data from 3154 ischemic stroke patients treated with intravenous thrombolysis from 2007 to 2013 were analyzed. The impact of door-to-treatment time on patients' length of hospital stay, discharge disposition, ambulatory status at discharge, and bleeding complications was assessed, controlling for patient-, hospital- and event-related characteristics. RESULTS: Patients who received intravenous thrombolysis within 30 minutes of hospital arrival had a 19% shorter (95% confidence interval [CI]: 2%-32%, P value = .04) hospital LOS than those treated for more than 120 minutes after arrival. Patients treated within 60 minutes of arrival were 27% more likely (odds ratio = 1.28, 95% CI: 1.06-1.56, P = .01) to have a better discharge disposition than patients treated after 60 minutes of arrival while having a similar rate of bleeding complications. CONCLUSIONS: Shortening the door-to-treatment time is associated with a decrease in patient LOS and better patient outcomes. Hospitals should be encouraged to measure, monitor, and reduce DTT time progressively for a better patient outcome.
