Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States

Abstract

Background and Purpose: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. Methods: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institute of Health Stroke Scale [NIHSS] score0–5) from October 1, 2016, to December 31, 2017. Patient-and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. Results: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59–79] years; median NIHSS score of 2 [interquartile range, 1–4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71–2.13], P <0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09–1.83], P <0.001). Conclusions: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

Efficacy and Safety of Adherence to dl-3-n-Butylphthalide Treatment in Patients With Non-disabling Minor Stroke and TIA—Analysis From a Nationwide, Multicenter Registry

“…Patients requiring intravenous thrombolysis and emergency revascularization were excluded from the present study; thus, many patients with potentially disabling stroke and large vessel stenosis or occlusion were excluded. Data from the United States showed that more than one-half of acute ischemic stroke hospitalizations had minor deficits, accounting for 4 of every 10 intravenous thrombolysis therapy (IVT) and 1 of every 10 mechanical thrombectomy treatments ( 18 ). A nationwide study in the United States, the excellent functional outcome only occurred in 48.2% of all minor strokes who underwent IVT or endovascular therapy (EVT) ( 18 ).…”

“…Data from the United States showed that more than one-half of acute ischemic stroke hospitalizations had minor deficits, accounting for 4 of every 10 intravenous thrombolysis therapy (IVT) and 1 of every 10 mechanical thrombectomy treatments ( 18 ). A nationwide study in the United States, the excellent functional outcome only occurred in 48.2% of all minor strokes who underwent IVT or endovascular therapy (EVT) ( 18 ). The exclusion of EVT and IVT minor ischemic stroke or TIA patients from the present study might contribute to the substantial-high proportion of favorable functional outcomes.…”

Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta‐analysis

“…There are geographic variations in IVT and EVT rates, with less than 8% to 10% and 2% IVT and EVT rates, respectively 6,7 . However, in optimized settings or some countries including—but not limited to—Austria, Denmark, the Netherlands, and United States; IVT and EVT rates of more than 10 and 3%, respectively, have been reported 6,8 . Furthermore, the outcomes of these treatments are highly time‐dependent, it is estimated every minute delay after stroke in an untreated patient leads to a loss of 1.9 million neurons, 9 and it has been observed that neurologic improvement and good functional outcome is associated with shorter time to reperfusion treatment 10 .…”

“…6,7 However, in optimized settings or some countries including-but not limited to-Austria, Denmark, the Netherlands, and United States; IVT and EVT rates of more than 10 and 3%, respectively, have been reported. 6,8 Furthermore, the outcomes of these treatments are highly time-dependent, it is estimated every minute delay after stroke in an untreated patient leads to a loss of 1.9 million neurons, 9 and it has been observed that neurologic improvement and good functional outcome is associated with shorter time to reperfusion treatment. 10 Thus, improvements to time delay to stroke treatment for AIS patients is essential because it can improve the number of patients treated with reperfusion therapy and patient outcomes.…”

Minor Non-Disabling Stroke Patients with Large Vessel Severe Stenosis or Occlusion Might Benefit from Thrombolysis

“…A recent study reported that more than one-half of acute ischemic stroke (AIS) hospitalizations had mild deficits, accounting for four of every 10 patients who received intravenous thrombolysis (IVT) therapy in national US practice [ 1 ]. Despite only initial mild neurological symptoms, nearly a third of patients with minor stroke not receiving alteplase treatment suffered functional disability at 90-day post stroke [ 2 , 3 , 4 ].…”