Christoph Gumbinger1, Peter Ringleb2, Franziska Ippen2, Matthias Ungerer2, Björn Reuter2, Ingo Bruder2, Michael Daffertshofer2, Christian Stock2. 1. From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany. christoph.gumbinger@med.uni-heidelberg.de. 2. From the Department of Neurology (C.G., P.R., F.I., M.U.) and Institute of Medical Biometry and Informatics (C.S.), University of Heidelberg; Department of Neurology and Geriatrics (B.R.), Helios Klinik Muellheim; Quality Assurance in Health Care Ltd (QiG BW GmbH) (I.B.), Stuttgart; Department of Neurology (M.D.), Klinikum Mittelbaden Rastatt-Forbach; and Stroke Working Group of Baden-Württemberg (P.R., M.D.), Germany.
Abstract
BACKGROUND: It is common practice to withhold IV thrombolysis (IVT) for acute ischemic stroke in patients with preexisting disabilities. To test the hypothesis of an association of IVT and good clinical outcome also in patients with preexisting disabilities without an increase in mortality, we analyzed data from 52,741 patients (15,317 treated with IVT) depending on prestroke Rankin Scale (pRS) score. METHODS: We performed an observational study based on a consecutive stroke registry covering 10.8 million inhabitants. The outcome at discharge of patients with stroke admitted in the time window of potential eligibility for IVT (<4.5 hours after stroke onset) was compared between patients treated and those not treated with thrombolysis, stratified by pRS score. Logistic regression analysis was used to estimate adjusted odds ratios (ORs) along with 95% confidence intervals (CIs) for favorable clinical outcome, defined as returning to the baseline pRS score or a score of 0 or 1 and mortality. Sensitivity analyses for subgroups of mildly and severely affected patients with stroke were performed, and the influence of treatment duration was assessed. RESULTS: Among included patients, IVT rates were 32% for patients with pRS scores of 0 to 1 and 20% for patients with pRS scores of 2 to 5. IVT in patients with pRS scores of 0 to 4 was associated with a higher chance of returning to the baseline pRS score (or a modified Rankin Scale score of 0/1), with ORs ranging between 1.42 (pRS score 2; 95% CI 1.16-1.73) and 1.73 (pRS score 0; 95% CI 1.61-1). The OR observed in patients with a pRS score of 5 was 0.65 (95% CI 0.25-1.70). Observed associations remained consistent in sensitivity analyses. Subgroup analyses revealed no evidence of bias due to potential floor and ceiling effects. No evidence of elevated in-hospital mortality of patients treated with thrombolysis was observed. CONCLUSIONS: Our study suggests that IVT can be effective even in patients with severe preexisting disabilities, provided that they were not bedridden before stroke onset. Withholding IVT on the sole ground of prestroke disabilities may not be justified.
BACKGROUND: It is common practice to withhold IV thrombolysis (IVT) for acute ischemic stroke in patients with preexisting disabilities. To test the hypothesis of an association of IVT and good clinical outcome also in patients with preexisting disabilities without an increase in mortality, we analyzed data from 52,741 patients (15,317 treated with IVT) depending on prestroke Rankin Scale (pRS) score. METHODS: We performed an observational study based on a consecutive stroke registry covering 10.8 million inhabitants. The outcome at discharge of patients with stroke admitted in the time window of potential eligibility for IVT (<4.5 hours after stroke onset) was compared between patients treated and those not treated with thrombolysis, stratified by pRS score. Logistic regression analysis was used to estimate adjusted odds ratios (ORs) along with 95% confidence intervals (CIs) for favorable clinical outcome, defined as returning to the baseline pRS score or a score of 0 or 1 and mortality. Sensitivity analyses for subgroups of mildly and severely affected patients with stroke were performed, and the influence of treatment duration was assessed. RESULTS: Among included patients, IVT rates were 32% for patients with pRS scores of 0 to 1 and 20% for patients with pRS scores of 2 to 5. IVT in patients with pRS scores of 0 to 4 was associated with a higher chance of returning to the baseline pRS score (or a modified Rankin Scale score of 0/1), with ORs ranging between 1.42 (pRS score 2; 95% CI 1.16-1.73) and 1.73 (pRS score 0; 95% CI 1.61-1). The OR observed in patients with a pRS score of 5 was 0.65 (95% CI 0.25-1.70). Observed associations remained consistent in sensitivity analyses. Subgroup analyses revealed no evidence of bias due to potential floor and ceiling effects. No evidence of elevated in-hospital mortality of patients treated with thrombolysis was observed. CONCLUSIONS: Our study suggests that IVT can be effective even in patients with severe preexisting disabilities, provided that they were not bedridden before stroke onset. Withholding IVT on the sole ground of prestroke disabilities may not be justified.
Authors: Katharina Althaus; Jens Dreyhaupt; Sonja Hyrenbach; Elmar H Pinkhardt; Jan Kassubek; Albert C Ludolph Journal: Ther Adv Neurol Disord Date: 2021-08-27 Impact factor: 6.570
Authors: Alexander Tinchon; Elisabeth Freydl; Robert D Fitzgerald; Christina Duarte; Michael Weber; Bernadette Calabek-Wohinz; Christoph Waiß; Stefan Oberndorfer Journal: J Neurol Date: 2022-07-19 Impact factor: 6.682