Patient refusal of thrombolytic therapy for suspected acute ischemic stroke


  • Conflict of interest: None declared.
  • Statistical Analysis performed by: Vahidy FS1 and Rahbar MH2,3
  • This work was supported by grants from the Howard Hughes Medical Institute (to SIS), and the National Institute of Health (P50 SPOTRIAS).
  • Search Terms: All Cerebrovascular Disease/Stroke [2], Professional Conduct and Ethics [90], Outcome Research [112]



To determine factors associated with patients refusing IV t-PA for suspected acute ischemic stroke (AIS), and to compare the outcomes of patients who refused t-PA (RT) with those treated with t-PA.


Patients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0–1), good (mRS: 0–2), and poor (mRS: 3–6).


Over 7·5 years, 30 (4·2%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 0·63, 95% CI 0·50–0·79). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 1·02, 95% CI 1·01–1·03), lower NIHSS (OR 1·11, 95% CI 1·03–1·18), a higher proportion of stroke mimics (OR 17·61, 95% CI 6·20–50·02) and shorter hospital stay (OR 1·32, 95% CI 1·09–1·61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 1·37, 95% CI 1·06–1·78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 1·61, 95% CI 0·69–3·73).


The incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out of six refusal patients (16·6%) had a stroke mimic.