Progression of stroke deficits in patients presenting with mild symptoms: The underlying etiology determines outcome

Background and purpose

Patients with acute stroke and mild or rapidly improving symptoms frequently show progression. The role of reperfusion treatment in such patients is not clear. We hypothesized that progression was most likely in patients with cortical localization and such patients may benefit from thrombolysis.

Material and methods

We interrogated Hamad Stroke Database to evaluate 90-days outcome in patients with acute ischemic stroke admitted within 4 hours and a NIHSS score of ≤6. Evaluation was based on localization (lacunar or cortical), multi-model imaging abnormalities and whether they received rt-PA. The 90-day mRS was used to determine outcome.

Results

During study period 6381 patients were admitted with acute stroke. Mild stroke within 4 hours was diagnosed in 506 [no thrombolysis: 381(lacunar: 213; cortical: 168), thrombolysis: 125 (lacunar: 45; cortical: 80)]. The rt-PA treated patients had significantly higher NIHSS (2.94±3.9 versus 1.28±2.46, p<0.0001), increased rates of complications (16.0% versus 3.9%, p<0.0001) and longer hospital stay (6.05±8.1 versus 3.78±3.6 days; p<0.001). In patients with cortical stroke, intracranial arterial occlusions (11.6% vs 3.9%, p<0.0001) and CTP mismatch (22.2% vs 4.4%, p<0.0001) were more frequent in rt-PA treated patients. Discharge mRS (33.6% versus 13.9%, p<0.001) and 90-days mRS (23.2% versus 11.8%, p = 0.002) was significantly worse in patients with cortical stroke (rt-PA-treated and untreated patients).

Conclusions

The outcome in patients with mild stroke depends on lesion location (lacunar versus cortical) and severity of symptoms. Patients who receive rt-PA have significantly larger deficits, increased imaging abnormalities and higher rates of hospital complication, explaining the poor outcome in such subjects.

Abstract TP214: Progression of Stroke Deficits in Patients Presenting With Mild Symptoms: The Underlying Etiology Determines Prognosis

Introduction: Many acute stroke patients present with mild symptoms, make it difficult to determine whether they should be treated with reperfusion strategies or not. The symptoms of such patients may frequently show progression. We hypothesized that localization based on clinical examination and multi-model imaging will be very helpful in determining patients most likely to have a bad outcome.

Methods: We interrogated the Hamad Stroke Database to evaluate 90-days outcome in patients with acute ischemic stroke admitted within 4 hours and a NIHSS score of ≤6. Patients were evaluated based on the localization (lacunar or cortical), abnormalities on multi-model imaging and whether they were treated with rt-PA or not. The 90-day mRS was used to determine outcome.

Results: During the study period 4016 patients were admitted with acute stroke. Mild stroke with arrival within 4 hours was diagnosed in 365 patients [no thrombolysis: 269 (lacunar: 155; cortical: 114), thrombolysis: 96 (lacunar: 38; cortical: 58)]. The rt-PA treated patients had significantly higher NIHSS (4.8±1.2 versus 2.3±1.6, p<0.0001), increased risk of complications (18.8% versus 4.1%, p<0.001) and longer hospital stay (median -Inter quartile range- 4 {2-6} versus 3 {2-5} days, p=0.002). Imaging abnormalities, including intracranial arterial occlusions and CTP mismatch were more frequent in rt-PA treated patients. The mRS at discharge (36.5% versus 14.8%, p<0.001) and 90 days (24% versus 12.6%, p=0.009) was significantly worse in patients with both cortical stroke in rt-PA-treated and untreated patients.

Conclusions: The prognosis in patients with mild stroke depends on location of the lesion (lacunar versus cortical). Patients who receive rt-PA have significantly larger deficits, increased imaging abnormalities and higher rates of complications that may explain the poor prognosis in such subjects.