Abstract
Early administration of tissue plasminogen activator (tPA) improves morbidity and mortality in acute ischemic stroke (AIS). However, the strict NINDS exclusion criteria, especially the emphasis on last known well times (LKWT) which are often unreliable in the acute setting, restrits tPA use to only 2-5% of all AIS patients. The MR-Witness and WAKE-UP trials propose using MRI diffusion-to-flair mismatch in these cases to better judge the age of an infarct, but the impact of this on post-discharge outcomes has not yet been reported. We conducted a retrospective analysis of all AIS patients in one comprehensive stroke center to further investigate this question. Of our total 1016 patients, 165 (16.2%) received tPA and 58 (5.7%) underwent mechanical thrombectomy. 380 patients (37.4%) were refused tPA due to an NINDS exclusion other than LKWT, 246 (24.2%) due to minimal or resolving neurological deficits, and 6 (0.6%) due to family preference. The remaining 161 patients (15.8%) were refused tPA only because of an unreliable LKWT. Statistical analyses comparing these 161 patients to the 165 who received tPA revealed no differences in age (p=0.306), gender (p=0.214), race, or even NIHSS score on presentation (p=0.306). However, while the total hospital stay was similar in both groups (p=0.954), patients who received tPA had significantly better post-discharge outcomes, with more patients going to acute rehab or home (p=0.033). In summary, comprehensive stroke centers generally out-perform national tPA administration averages (16.2% in our stroke center compared to 2-5% nationally). However, our study showed that a large percentage of AIS patients are still refused tPA only because of an unreliable LKWT. Obtaining emergent MRIs to assess diffusion-to-flair mismatch in these cases may increase the number of people with AIS eligible for tPA and substantially improve their post-discharge outcomes.
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