Original Article
Intravenous Tissue Plasminogen Activator for Patients with Minor Ischemic Stroke

https://doi.org/10.1016/j.jstrokecerebrovasdis.2011.03.009Get rights and content

Background

Patients with minor ischemic stroke (MIS) are frequently excluded from thrombolytic therapy. Denial of therapy to these patients, however, remains controversial. We compared outcomes in patients with MIS who received intravenous (IV) tissue plasminogen activator (t-PA) with those who were not treated.

Methods

We selected adult patients with stroke onset within 3 hours from a prospectively collected stroke registry. MIS was defined as an admission National Institutes of Health Stroke Scale (NIHSS) score ≤5. The primary outcome was a 90-day modified Rankin scale (mRS) score of 0 to 1. Secondary outcomes were a Barthel index (BI) score ≥95 at 90 days, symptomatic intracranial hemorrhage (SICH), and death. Multivariable logistic regression was performed to determine the association between outcomes adjusting for age, history of diabetes, and NIHSS score at admission. Reasons for t-PA exclusion were obtained.

Results

We identified 133 patients with MIS; 59 patients received IV t-PA. The NIHSS score (mean ± SD) at admission was higher in the t-PA treated group (3.4 ± 1.4 v 1.9 ± 1.3 in the untreated group; P < .0001). Other baseline characteristics were not significantly different between the 2 groups. At 90 days, 57.6% of patients in the t-PA group and 68.9% of patients in the untreated group had a mRS score of 0 to 1 (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.39-2.2; P = .87). A BI score of 95 to 100 was achieved in 75% of patients in the IV t-PA group versus 78.9% in the untreated group (OR 1.18, 95% CI 0.43-3.23; P = .74). There were 3 deaths (5.1%) in the IV t-PA group and 3 deaths (4.1%) in the control group.

Conclusions

In our sample, patients with MIS treated with IV t-PA have similar outcomes as patients not receiving thrombolysis. A randomized trial or larger observational study is needed confirm or reject these findings.

Section snippets

Methods

Between January 2005 and June 2010, we selected patients from a prospective stroke database who presented to the emergency department within 3 hours from stroke onset and had an admission NIHSS score ≤5. Patients were divided into 2 groups: (1) patients treated with IV t-PA and (2) patients not given any thrombolytic therapy. Patients treated with intraarterial t-PA or other experimental therapies were excluded. All patients received modified Rankin scale (mRS) and Barthel index (BI) scores 90

Results

We identified 133 patients with MIS; from them, 59 patients received IV t-PA and 74 did not receive any thrombolytic therapy (untreated group). Baseline characteristics (age, gender, race, hypertension, atrial fibrillation, diabetes, tobacco use, and prestroke mRS score) were well matched between both groups, with the exception of the initial NIHSS score (mean ± standard deviation [SD], median, Q1, Q3: IV t-PA group 3.4 ± 1.4, 4, 2.5, 5; untreated group 1.9 ± 1.3, 2, 1, 2; P < .0001 [Table 1]).

Discussion

This study reveals no difference in clinical and safety outcomes between MIS patients treated with or without IV t-PA. The rate of SICH, although not registered in the untreated group, was within the expected range and did not alter the rates of mortality or disability in the treated group. However, because higher NIHSS scores predict a higher rate of SICH, and because few previous studies of minor stroke patients treated with IV t-PA have shown a SICH rate between 0% and 2%,8, 9 it could be

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Supported by National Institutes of Health educational grant to UCSD Stroke Center.

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