NASHVILLE—Approximately one-third of patients with ischemic stroke whom neurologists consider too good to treat are unable to be discharged home, according to research presented at the 2015 International Stroke Conference. Mild or rapidly improving symptoms among patients with stroke often persuade neurologists not to administer treatment, even if the patients arrive at the hospital during the period of eligibility for IV t-PA. Several studies have reported poor outcomes among these patients, however.
Khawja A. Siddiqui, MD, Clinical Research Fellow at Massachusetts General Hospital in Boston, and colleagues sought to identify patient and imaging characteristics associated with poor outcomes in this group of patients. The investigators used their hospital’s Get With the Guidelines database to examine data for 2,745 consecutive patients with stroke admitted between January 2009 and July 2013. They performed univariate and multivariable analyses to determine factors associated with the poor outcome of not being discharged home.
Khawja A. Siddiqui, MD
Of the 2,745 patients, 306 (11.1%) presented within the window for IV t-PA, but did not receive the treatment because their symptoms were considered too mild or improved rapidly. Of these individuals, imaging characteristics were available for 238 patients. Among patients with stroke considered too good to treat, 62.6% were discharged home, 26.9% were discharged to inpatient rehabilitation facilities, 8.4% were discharged to skilled nursing facilities, and 2.1% were discharged to hospice or died.
Compared with patients who had favorable outcomes, patients with poor outcomes were older, more likely to be Hispanic, had more vascular risk factors, and had a higher NIH Stroke Scale (NIHSS) score. Furthermore, infarcts in both hemispheres, and posterior circulation infarcts with or without an anterior circulation infarct were more common among patients with poor outcomes. Multivariable analysis indicated that increasing age, Hispanic ethnicity, higher NIHSS score, and bihemispheric stroke were associated with poor outcome. In addition, poor outcome tended to occur among patients with small vessel stroke.
“Our study is the first to use imaging and infarct characteristics to look at too-good-to-treat patients,” said Dr. Siddiqui. “On the basis of the data that we have, it is difficult to say which of these patients might or might not have benefited from t-PA.”
Factors such as advanced age, higher NIHSS score, and bihemispheric infarction should be considered in t-PA decision-making in patients who could be considered too good to treat, he added. “Large, multicenter, prospective studies are needed to better identify potential biomarkers of poor outcomes in this group.”
—Erik Greb