Role of Preexisting Disability in Patients Treated With Intravenous Thrombolysis for Ischemic Stroke

Abstract

Background and Purpose— Little is known about the effect of thrombolysis in patients with preexisting disability. Our aim was to evaluate the impact of different levels of prestroke disability on patients’ profile and outcome after intravenous thrombolysis. Methods— We analyzed the data of all stroke patients admitted between October 2003 and December 2011 that were contributed to the Safe Implementation of Treatments in Stroke–Eastern Europe (SITS-EAST) registry. Patients with no prestroke disability at all (modified Rankin Scale [mRS] score, 0) were used as a reference in multivariable logistic regression. Results— Of 7250 patients, 5995 (82%) had prestroke mRS 0, 791 (11%) had prestroke mRS 1, 293 (4%) had prestroke mRS 2, and 171 (2%) had prestroke mRS ≥3. Compared with patients with mRS 0, all other groups were older, had more comorbidities, and more severe neurological deficit on admission. There was no clear association between preexisting disability and the risk of symptomatic intracranial hemorrhage. Prestroke mRS 1, 2, and ≥3 were associated with increased risk of death at 3 months (odds ratio, 1.3, 2.0, and 2.6, respectively) and lower chance of achieving favorable outcome (achieving mRS 0–2 or returning to the prestroke mRS; 0.80, 0.41, 0.59, respectively). Patients with mRS ≥3 and 2 had similar vascular profile and favorable outcome (34% versus 29%), despite higher mortality (48% versus 39%). Conclusions— Prestroke disability does not seem to independently increase the risk of symptomatic intracranial hemorrhage after thrombolysis. Despite higher mortality, 1 in 3 previously disabled patients may return to his/her prestroke mRS. Therefore, they should not be routinely excluded from thrombolytic therapy.

Intravenous Thrombolysis in Patients Dependent on the Daily Help of Others Before Stroke

“…This observation is unpreceded and differed from the result of a subgroup analysis in another study, suggesting a higher risk of poor outcome in patients with preexisting dependency (OR adjusted , 1.70; 0.99-2.94). 12 Unexpectedly, among survivors, previously dependent patients had better odds to avoid poor outcome than independent patients in our cohort if age and stroke severity were taken into account. We can only speculate on possible reasons: (1) our definition of poor outcome (which we adopted from a previous study 12 ) differed between both groups and may have favored the previously dependent patients.…”

“…12 Unexpectedly, among survivors, previously dependent patients had better odds to avoid poor outcome than independent patients in our cohort if age and stroke severity were taken into account. We can only speculate on possible reasons: (1) our definition of poor outcome (which we adopted from a previous study 12 ) differed between both groups and may have favored the previously dependent patients. In detail, among survivors, dependent patients with a prestroke mRS score of 3 can only move to an mRS score of 4 or 5, patients with a GFR indicates glomerular filtration rate; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; poor outcome, not reaching at least prestroke mRS in previously dependent patients (mRS score of 3 to 6 in previously independent patients); prestroke completely dependent, prestroke mRS score of 4 to 5; prestroke dependent, prestroke mRS score of 3 to 5; prestroke independent, prestroke mRS score of 0 to 2; prestroke partially dependent, prestroke mRS score of 3; and sICH, symptomatic intracranial hemorrhage (European Cooperative Acute Stroke Study [ECASS] II definition).…”

“…This rate is comparable with previous observations in smaller studies, in which 7 of 14 patients, and 49% among 171 patients with previous dependency (applying the same definition as in our cohort) died within 3 months. 4,12 As a refinement, our data allowed an estimate of the mortality risk. After adjustment for confounding variables, being previously dependent meant that the likelihood was twice as high to die within the next 3 months after IVT when compared with previously independent patients treated with IVT.…”

“…Outcome and complication measures were as follows: (1) poor functional 3-month outcome, defined as 3-month mRS score of 3 to 6 in previously independent patients and a 3-month mRS higher than the prestroke mRS in previously dependent patients as applied in previous research 12 and shown in Figure 1, (2) death, and (3) symptomatic ICH (sICH) according to criteria of the European Cooperative Acute Stroke Study (ECASS)-II trial.…”

Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

“…Research has explored whether or not pre-stroke disability was associated with negative outcomes of thrombolysis. 44 It was concluded that pre-stroke disability does not independently increase the risk of sICH after thrombolysis. However, higher modified Rankin Scale (mRS) scores (high scores indicating greater dependency on others for assistance with daily living) were associated with an increased risk of death at 3 months post treatment.…”