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Intravenous thrombolysis for acute ischemic stroke patients presenting with mild symptoms

Authors

  • Daniel Strbian,

    Corresponding author
    • Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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    • Conflicts of interest: D. S. reports no disclosures. A. M. received honoraria for educational symposia, and payments for consultations from Boehringer Ingelheim. K. P. reports no disclosures. T. S. received modest honoraria from Boehringer Ingelheim for speaking. J. P., M. T., and V. A. report no disclosures. KR received honoraria from Boehringer-Ingelheim for speaking. O. H. received honoraria from Boehringer Ingelheim. M. K. received honoraria from Boehringer Ingelheim, PAION AG, Forest Research Laboratories Inc., and Lundbeck AS for participating in Steering Committee meetings of all European Cooperative Acute Stroke Study and Desmoteplase in Acute Ischemic Stroke Trial (DIAS) trials, and is a consultant and on the Advisory Boards of Boehringer Ingelheim, PAION AG, Forest Research Laboratories Inc., and Lundbeck AS. P. J. L. reports no disclosures.
  • Katja Piironen,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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    • Conflicts of interest: D. S. reports no disclosures. A. M. received honoraria for educational symposia, and payments for consultations from Boehringer Ingelheim. K. P. reports no disclosures. T. S. received modest honoraria from Boehringer Ingelheim for speaking. J. P., M. T., and V. A. report no disclosures. KR received honoraria from Boehringer-Ingelheim for speaking. O. H. received honoraria from Boehringer Ingelheim. M. K. received honoraria from Boehringer Ingelheim, PAION AG, Forest Research Laboratories Inc., and Lundbeck AS for participating in Steering Committee meetings of all European Cooperative Acute Stroke Study and Desmoteplase in Acute Ischemic Stroke Trial (DIAS) trials, and is a consultant and on the Advisory Boards of Boehringer Ingelheim, PAION AG, Forest Research Laboratories Inc., and Lundbeck AS. P. J. L. reports no disclosures.
  • Atte Meretoja,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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    • Conflicts of interest: D. S. reports no disclosures. A. M. received honoraria for educational symposia, and payments for consultations from Boehringer Ingelheim. K. P. reports no disclosures. T. S. received modest honoraria from Boehringer Ingelheim for speaking. J. P., M. T., and V. A. report no disclosures. KR received honoraria from Boehringer-Ingelheim for speaking. O. H. received honoraria from Boehringer Ingelheim. M. K. received honoraria from Boehringer Ingelheim, PAION AG, Forest Research Laboratories Inc., and Lundbeck AS for participating in Steering Committee meetings of all European Cooperative Acute Stroke Study and Desmoteplase in Acute Ischemic Stroke Trial (DIAS) trials, and is a consultant and on the Advisory Boards of Boehringer Ingelheim, PAION AG, Forest Research Laboratories Inc., and Lundbeck AS. P. J. L. reports no disclosures.
  • Tiina Sairanen,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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  • Jukka Putaala,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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  • Marjaana Tiainen,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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  • Ville Artto,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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  • Kirsi Rantanen,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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  • Olli Häppölä,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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  • Markku Kaste,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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  • Perttu J. Lindsberg,

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
    2. Research Programs Unit, Molecular Neurology, Biomedicum Helsinki, and Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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  • Helsinki Stroke Thrombolysis Registry Group


  • Equal contribution.

Correspondence: Daniel Strbian*, Department of Neurology, Helsinki University Central Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland.

E-mail: daniel.strbian@hus.fi

Abstract

Background

Thrombolysis of ischemic stroke patients presenting with mild symptoms is controversial.

Aim

We aimed to describe the clinical outcome and frequency of infarcts and symptomatic intracerebral hemorrhages on follow-up imaging of such thrombolysis-treated patients.

Methods

Our cohort included 1398 consecutive ischemic stroke patients treated with intravenous thrombolysis at the Helsinki University Central Hospital, years 1995–2010. We analyzed the patients according to baseline National Institutes of Health Stroke Scale: ≤2, 3–4, 5–6, and >6. In our institution, visualization of an artery occlusion or perfusion deficit is required for thrombolysis with National Institutes of Health Stroke Scale ≤ 2. We used univariate and multivariable methods to describe the cohort and study associations between the variables. Excellent three-month outcome was defined as modified Rankin Scale 0–1.

Results

Fifty-eight (4·1%) patients were treated with National Institutes of Health Stroke Scale ≤ 2, another 194 (13·6%) with 3–4 points, and 236 (16·5%) with 5–6 points. With National Institutes of Health Stroke Scale ≤ 2, 45 (78%) of the patients had excellent three-month outcome, achieved in 116 (59%) patients with National Institutes of Health Stroke Scale 3–4, in 130 (55%) with National Institutes of Health Stroke Scale 5–6, and in 241 (26%) with National Institutes of Health Stroke Scale > 6. Frequencies of symptomatic intracerebral hemorrhage (European Cooperative Acute Stroke Study-2) were 0%, 2·6%, 2·1%, and 8·1%, and visible infarcts on follow-up imaging 48%, 43%, 48%, and 74%, respectively. In patients with baseline National Institutes of Health Stroke Scale ≤ 6, poor outcome was associated with previous stroke, diabetes, elevated admission blood glucose, and development of intracerebral hemorrhage.

Conclusions

Half of patients presenting with National Institutes of Health Stroke Scale 0–6 developed an infarction despite thrombolysis, and 40% had poor outcome, which was associated with glucose metabolism and hemorrhagic complications. Managing thrombolysis candidates with mild symptoms warrants individual consideration often supported by multimodal imaging.

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