Predictors of in-hospital mortality and dependence at discharge in patients with MCA stroke with intravenous thrombolysis

[Comparative characteristics of the efficacy and safety of the original alteplase and its complete biosimilar in the treatment of ischemic stroke in real clinical practice]

OBJECTIVE

To conduct a comparative analysis between the original alteplase and its biosimilar in terms of efficacy and safety in real clinical practice in the Republic of Belarus.

MATERIAL AND METHODS

The cohort study included 420 patients. All included patients underwent thrombolytic therapy with alteplase within 4.5 hours of the onset of stroke symptoms according to the approved tactics of the Republic of Belarus and international recommendations. The patients were divided into 2 groups: 215 received the drug Revelisa, 205 - Actilyse.

RESULTS

The patients were comparable in gender, age, ASPECTS assessment, but had statistically significant difference in NIHSS was found, due to the large number of patients with NIHSS=16-25 in the Actilyse group. The assessment of premorbid disability also showed a statistically significant difference: there were more patients in the Revelisa group who had functional limitations of varying degrees before the disease, 83 (38.6%) versus 62 (28.3%) patients in the comparison group. Clinical outcomes were comparable, the proportion of patients achieving mRS=0-1 at discharge was 41.5% in group A and 42.8% in group P. The Revelisa demonstrated a statistically significant lower number of deaths in 15 (7.0%) and 29 (14.1%) in the comparison group. The development of a greater number of clinically insignificant petechial hemorrhages was noted after the use of Actilyse.

CONCLUSION

The analysis demonstrated a high level of safety in the use of alteplase preparations in routine practice. The compared fibrinolytics had comparable effectiveness in achieving functional independence after ischemic stroke, despite the more premorbid disability of patients who received a biosimilar.

Time-dependence of NIHSS in predicting functional outcome of patients with acute ischemic stroke treated with intravenous thrombolysis

OBJECTIVES

The National Institute of Health Stroke Scale (NIHSS) is a predictor for the prognosis of acute ischaemic stroke (AIS) and its prediction is time-dependent. We examined the performance of NIHSS at different timepoints in predicting functional outcome of patients with thrombolysed AIS.

METHODS

This prospective study included 269 patients with AIS treated with recombinant tissue plasminogen activator (rt-PA). Unfavourable functional outcome was defined as modified Rankin Scale score 4-6 at 3 months after rt-PA treatment. Receiver operating characteristic curves were used to examine the predictive power of NIHSS score at admission and 2 hours/24 hours/7 days/10 days after rt-PA treatment. Youden's index was used to select the threshold of NIHSS score. Logistic regression was used to estimate the ORs of unfavourable functional outcome for patients with NIHSS score higher than the selected thresholds.

RESULTS

The threshold of NIHSS score at admission was 12 (sensitivity: 0.51, specificity: 0.84) with an acceptable predictive power (area under curve [AUC] 0.74) for unfavourable functional outcome. The threshold changed to 5 at 24 hours after rt-PA treatment (sensitivity: 0.83, specificity: 0.65) and remained unchanged afterwards. The predictive power and sensitivity sequentially increased over time and peaked at 10 days after rt-PA treatment (AUC 0.92, sensitivity: 0.85, specificity: 0.80). NIHSS scores higher than the thresholds were associated with elevated risk of unfavourable functional outcome at all timepoints (all p<0.001).

CONCLUSIONS

NIHSS is time-dependent in predicting AIS prognosis with increasing predictive power over time. Since patients whose NIHSS score ≥ 12 are likely to have unfavourable functional outcome with rt-PA treatment only, mechanical thrombectomy should be largely taken into consideration for these patients.