Abstract
At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0–1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13–5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23–4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43–12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.
Highlights
Stroke incidence in China is very high, with ∼2.5 million cases annually [1], of which 30% are mild ischemic strokes [2, 3]
Laboratory findings were comparable for patients in these two groups, with recombinant tissue plasminogen activator (rt-PA) Benefits large-artery atherosclerosis (LAA) Without Tandem the exception of LDL-C levels, which were elevated in patients in the rt-PA-treated group relative to untreated controls (2.5 ± 0.8 vs. 2.3 ± 0.8; P = 0.018)
We found that rt-PA-treated patients exhibited a non-significant trend toward more favorable outcomes relative to untreated patients after adjusting for age, sex, NIHSS score and OTT time (OR, 1.65; 95% CI, 0.96–2.86; P = 0.072), with 82.5% (132/160) in rt-PA treated group having good outcome at 90 days, while the proportion was 74.9% (134/179) in the untreated group
Summary
Stroke incidence in China is very high, with ∼2.5 million cases annually [1], of which 30% are mild ischemic strokes [2, 3]. Mild stroke represents one of the main reasons for not receiving intravenous recombinant tissue plasminogen activator (rt-PA) in time-eligible acute ischemic stroke (AIS) patients [4, 5]; this is despite current guidelines which make no formal recommendations on of the use of rt-PA in these patients [6]. Cases of mild stroke have been excluded due to contraindications from most randomized thrombolysis trials citing reasons that symptoms were not severe enough to warrant a high-risk treatment intervention; these decisions are not support by data [7]. It must be noted that there is substantive evidence to suggest that a significant proportion of mild stroke patients has subsequent neurological deterioration [8,9,10]. A retrospective analysis indicated that both primary rt-PA and endovascular therapy had better outcome at 90 days than primary conservative therapy in patients with large vessel occlusion in the anterior circulation and low NIHSS score (NIHSS score ≤ 5) [13]
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