Thrombolysis for Acute Minor Stroke: Outcome and Barriers to Management

Abstract

Background: We evaluated the management, outcome and haemorrhagic risk in a cohort of ischaemic stroke patients with mild symptoms treated with intravenous tissue plasminogen activator (tPA) within the first 4.5 h. Methods: We analysed data from a prospective stroke thrombolysis registry. A total of 1,043 patients received tPA between 2010 and 2014 in the 5 stroke units of the RESUVAL stroke network (Rhône Valley, France). Among them, 170 patients had a National Institute of Health Stroke Scale (NIHSS) score ≤4 (minor group: MG) before tPA and 873 patients had a NIHSS score >4. Results: A high rate (77%) of excellent outcome (3-month-modified Rankin Scale score ≤1) was observed in the MG. No symptomatic intracerebral haemorrhage occurred and the rate of any haemorrhagic transformation was 5%. Fifty-four percent of the MG patients had visible arterial occlusion before tPA. Patients of the MG were less likely to be transported by Emergency Medical Services and to be directly admitted to the stroke unit or to imaging. Median delays from onset to admission, from admission to imaging and from onset to tPA were longer in the MG. Conclusion: Our data provided evidence of safety and suggested potential benefit of thrombolysis in patients with NIHSS score ≤4. A majority of these patients exhibited arterial occlusion before thrombolysis. Most often, patients with mild stroke are not given priority in terms of the mode of transport, direct admission to stroke unit and rapid imaging, resulting in an increased delay from onset to thrombolysis. Health system improvements are needed to provide all suspected stroke victims equal access to imaging and treatment on an emergency basis.

Determinants of Emergency Medical Services Utilization Among Acute Ischemic Stroke Patients in Hubei Province in China

“…4 Utilization of emergency medical services (EMS) can increase the likelihood of appropriate therapy with recombinant tissue-type plasminogen activator. 5,6 Recently, several studies have been conducted to investigate EMS utilization and its influencing factors with acute stroke in developed countries. 7,8 However, information about EMS utilization among AIS patients in China is still unclear.…”

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

“…229 The description for this network included a statement that government policy had been put in place to monitor development, but no outputs have been identified. (b) Studies reporting data on activity within clinical networks for specific conditions such as stroke, 230,231 trauma, 232,233 primary or community care 234,235 and ST elevation myocardial infarction. 236 Most of these studies claimed that clinical networks had improved care by, for example, increasing numbers of patients admitted to specialist facilities, 230,232 receiving thrombolysis for stroke 231 and improving mortality from trauma, 233 but all of them reported current activity and had not made any assessment of differences in care compared with before the network became operational or, therefore, whether the network had improved care.…”

Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke

“…Despite mild neurological symptoms, an intra-arterial occlusion is evident on computerized tomographic angiogram (CTA) in 10% to 54% of MIS patients, and 30% have persistent disability at 90 days. [1][2][3] Mild clinical deficits with low National Institutes of Health Stroke Scale (NIHSS) scores remain a frequent reason for IV-tPA exclusion. This represents a missed opportunity to administer an effective therapy to an at-risk population.…”