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14-09-2011 | Stroke | Article

Concerns over acute management of mild stroke


Free abstract

MedWire News: More than one in four patients with mild or rapidly improving stroke symptoms who do not receive intravenous recombinant tissue plasminogen activator (rtPA) have poor outcomes, report the Get With The Guidelines (GWTG)-Stroke investigators.

"Physicians should not assume that patients with initially mild or rapidly improving ischemic stroke symptoms are at low risk for requiring inpatient care or rehabilitation after hospital discharge," say Eric Smith (University of Calgary, Alberta, Canada) and colleagues.

They add: "A randomized, controlled trial of rtPA for treatment of mild or rapidly improving stroke should be considered."

Of 93,517 patients arriving at GWTG hospitals within 2 hours of symptom onset, between 2003 and 2009, 31.2% were not given rtPA solely because they had mild or rapidly improving symptoms.

But, at discharge, 28.5% of these patients were unable to walk without assistance and 28.3% were unable to return home, Smith et al report in the journal Stroke. The patients not discharged home comprised 1.1% (of the whole cohort) who died, 0.8% who were discharged to a hospice, 10.7% who were sent to a skilled nursing facility, and 15.7% who were referred for acute rehabilitation.

The patients' median National Institutes of Health Stroke Scale (NIHSS) score was just 2; however, the NIHSS score was only recorded for 61.9% of patients.

Patients' NIHSS scores were strongly linked with their chances of being discharged home; each 1-point increase was associated with an 11% reduction in the odds of home discharge. Older age also had an impact, with each 10-year increase in patient age reducing the odds by 37%.

Having hypertension, diabetes, or peripheral vascular disease reduced patients' chances of home discharge, but patients had an increased chance of home discharge if they were receiving lipid-lowering therapy.

In an accompanying editorial, Clotilde Balucani and Steven Levine (State University of New York Downstate Medical Center, Brooklyn, USA) said that "these are key data to argue for a more effective approach to these [acute ischemic stroke] patients."

They noted that there are no generally accepted definitions of mild stroke and rapidly improving symptoms, and that the two conditions are often counted together, including in the GWTG study. "This lack of clear distinction between mild stroke and RISS [rapidly improving stroke symptoms] makes the process of dissecting out the specific barriers limiting the use of [intravenous] rtPA more difficult."

Balucani and Levine concluded: "The time to improve outcomes of patients with mild stroke and RISS has come, by using new approaches to definitions, assessments, education, earlier vascular diagnostic investigations, and risk-benefit analyses."

MedWire ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2011

By Eleanor McDermid