International Journal of Neuroscience, 2015; 0(0): 1–3 Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 0020-7454 print / 1543-5245 online DOI: 10.3109/00207454.2015.1002611
ORIGINAL ARTICLE
Predictors of major improvement after intravenous thrombolysis in acute ischemic stroke Shadi Yaghi,1 Archana Hinduja,2 and Nicolas Bianchi2 1
Int J Neurosci Downloaded from informahealthcare.com by Gazi Univ. on 05/04/15 For personal use only.
Division of Stroke and Cerebrovascular Diseases, Neurology Department, Columbia University Medical Center, New York, NY, USA; 2 Department of Neurology, University of Arkansas for Medical Sciences, Litte Rock, AR, USA Background: Intravenous thrombolysis improves outcomes of stroke patients. The immediate response to thrombolysis is variable and few studies attempted to identify predictors of major neurological improvement (MNI) 24 h following thrombolysis. Our objective is to determine predictors of MNI 24 h following thrombolysis. Methods: We reviewed the prospective database of patients treated through our telestroke network and at our institution between November 2008 and June 2012. We included all patients who received IV t-PA and had a 24-h NIHSS score available. Similar to previous studies, we defined MNI as a reduction in NIHSS score by ≥8 points, or a score of 0 or 1 at 24 h. Demographics, risk factors, time to treatment, and clinical and laboratory data, were compared between MNI present or absent. Baseline predictors were compared using t- and Fisher’s exact tests, and outcomes using multivariate logistic regression analysis. Results: Out of 316 patients, 306 had 24-h NIHSS scores and 38% of them experienced MNI. Patients with MNI were less likely to be older than 80 years (16% vs. 29%, p = 0.008) and to have atrial fibrillation (9% vs. 24%, p = 0.001) compared to those without; we found no other predictors of MNI. After adjusting for baseline demographics and risk factors, age less than 80 years (OR = 1.9, 95% CI 1.1–3.6) and absence of atrial fibrillation (OR = 3.0, 95% CI: 1.4–6.2) predicted MNI. Conclusion: Major neurological improvement within 24 h after thrombolysis is more likely in younger patients and those without atrial fibrillation. KEYWORDS: ischemic stroke, thrombolysis, outcome, major neurological improvement, atrial fibrillation
Introduction Intravenous recombinant tissue plasminogen activator (IV rtPA) improves outcomes of stroke patients treated within 4.5 h from symptoms onset [1, 2]. However, the immediate response to thrombolysis is variable. While some patients have significant improvement within 24 h from treatment, others remain clinically unchanged despite thrombolytic therapy. Identifying predictors of major neurological improvement may help physicians select patients as candidates for additional interventional therapy. Very few studies with conflicting results attempted to identify predictors of major neurological improvement (MNI) 24 h following thrombolysis [3–5]. Our aim is to identify admission factors that predict MNI Received 26 October 2014; revised 22 December 2014; accepted 23 December 2014. Correspondence: Shadi Yaghi, MD, Division of Stroke and Cerebrovascular Diseases, Neurology Department, Columbia University Medical Center, The Neurological Institute of New York, 710 W. 168th Street, New York, NY 10032, USA. Tel: 212-305-1710. E-mail: [email protected]
after thrombolytic therapy. In secondary analyses, we explored if MNI correlated with a favorable 3-month outcome.
Methods Study population This study was approved by the University of Arkansas institutional review board. We reviewed the prospective database of patients treated through our telestroke network and at our institution between November 2008 and June 2012. We included all patients who received IV rtPA and had a 24-h NIHSS score available in our records. In our institution, all patients treated with thrombolytic therapy have an admission NIHSS score followed by a 24-h NIHSS score performed by NIHSS certified care providers.
Major neurological improvement The primary outcome was major neurological improvement 24 h after thrombolytic therapy. This was defined 1
2
S. Yaghi et al.
similar to prior studies, as a reduction in NIHSS score by ≥ 8 points [3, 5, 6] or a score of 0 or 1 at 24 h [6].
Table 1. Patient’s characteristics based on 24-h major neurological improvement (MNI) status. MNI (n = 116)
Predictors of major neurological improvement Clinical predictors
Int J Neurosci Downloaded from informahealthcare.com by Gazi Univ. on 05/04/15 For personal use only.
–Baseline demographics: Age ( 2 (%)
No MNI (n = 190)
51% 55% 65.6 ± 14.2 69.3 ± 15.4 16% 29% 80% 82% 23% 26% 41% 37% 9% 24% 80% 85%
p 0.555 0.036 0.008 0.766 0.589 0.629 0.001 0.206
12 3 151 ± 50
12 11 157 ± 50
0.719
ORIGINAL ARTICLE
Predictors of major improvement after intravenous thrombolysis in acute ischemic stroke Shadi Yaghi,1 Archana Hinduja,2 and Nicolas Bianchi2 1
Int J Neurosci Downloaded from informahealthcare.com by Gazi Univ. on 05/04/15 For personal use only.
Division of Stroke and Cerebrovascular Diseases, Neurology Department, Columbia University Medical Center, New York, NY, USA; 2 Department of Neurology, University of Arkansas for Medical Sciences, Litte Rock, AR, USA Background: Intravenous thrombolysis improves outcomes of stroke patients. The immediate response to thrombolysis is variable and few studies attempted to identify predictors of major neurological improvement (MNI) 24 h following thrombolysis. Our objective is to determine predictors of MNI 24 h following thrombolysis. Methods: We reviewed the prospective database of patients treated through our telestroke network and at our institution between November 2008 and June 2012. We included all patients who received IV t-PA and had a 24-h NIHSS score available. Similar to previous studies, we defined MNI as a reduction in NIHSS score by ≥8 points, or a score of 0 or 1 at 24 h. Demographics, risk factors, time to treatment, and clinical and laboratory data, were compared between MNI present or absent. Baseline predictors were compared using t- and Fisher’s exact tests, and outcomes using multivariate logistic regression analysis. Results: Out of 316 patients, 306 had 24-h NIHSS scores and 38% of them experienced MNI. Patients with MNI were less likely to be older than 80 years (16% vs. 29%, p = 0.008) and to have atrial fibrillation (9% vs. 24%, p = 0.001) compared to those without; we found no other predictors of MNI. After adjusting for baseline demographics and risk factors, age less than 80 years (OR = 1.9, 95% CI 1.1–3.6) and absence of atrial fibrillation (OR = 3.0, 95% CI: 1.4–6.2) predicted MNI. Conclusion: Major neurological improvement within 24 h after thrombolysis is more likely in younger patients and those without atrial fibrillation. KEYWORDS: ischemic stroke, thrombolysis, outcome, major neurological improvement, atrial fibrillation
Introduction Intravenous recombinant tissue plasminogen activator (IV rtPA) improves outcomes of stroke patients treated within 4.5 h from symptoms onset [1, 2]. However, the immediate response to thrombolysis is variable. While some patients have significant improvement within 24 h from treatment, others remain clinically unchanged despite thrombolytic therapy. Identifying predictors of major neurological improvement may help physicians select patients as candidates for additional interventional therapy. Very few studies with conflicting results attempted to identify predictors of major neurological improvement (MNI) 24 h following thrombolysis [3–5]. Our aim is to identify admission factors that predict MNI Received 26 October 2014; revised 22 December 2014; accepted 23 December 2014. Correspondence: Shadi Yaghi, MD, Division of Stroke and Cerebrovascular Diseases, Neurology Department, Columbia University Medical Center, The Neurological Institute of New York, 710 W. 168th Street, New York, NY 10032, USA. Tel: 212-305-1710. E-mail: [email protected]
after thrombolytic therapy. In secondary analyses, we explored if MNI correlated with a favorable 3-month outcome.
Methods Study population This study was approved by the University of Arkansas institutional review board. We reviewed the prospective database of patients treated through our telestroke network and at our institution between November 2008 and June 2012. We included all patients who received IV rtPA and had a 24-h NIHSS score available in our records. In our institution, all patients treated with thrombolytic therapy have an admission NIHSS score followed by a 24-h NIHSS score performed by NIHSS certified care providers.
Major neurological improvement The primary outcome was major neurological improvement 24 h after thrombolytic therapy. This was defined 1
2
S. Yaghi et al.
similar to prior studies, as a reduction in NIHSS score by ≥ 8 points [3, 5, 6] or a score of 0 or 1 at 24 h [6].
Table 1. Patient’s characteristics based on 24-h major neurological improvement (MNI) status. MNI (n = 116)
Predictors of major neurological improvement Clinical predictors
Int J Neurosci Downloaded from informahealthcare.com by Gazi Univ. on 05/04/15 For personal use only.
–Baseline demographics: Age ( 2 (%)
No MNI (n = 190)
51% 55% 65.6 ± 14.2 69.3 ± 15.4 16% 29% 80% 82% 23% 26% 41% 37% 9% 24% 80% 85%
p 0.555 0.036 0.008 0.766 0.589 0.629 0.001 0.206
12 3 151 ± 50
12 11 157 ± 50
0.719
