Background:
Rapidly improving stroke symptoms (RISS) is a frequently cited reason for not giving IV rt-PA. However, prior studies have suggested that outcome of acute ischemic stroke patients presenting with RISS is not invariably benign. This raises the possibility that stroke-related disability may be relatively common after RISS.
Objective:
To explore both discharge disposition and 3-month CT lesion volume in patients with and without RISS based on various pre-specified definitions in The NINDS rt-PA Stroke Study cohort.
Methods:
The NINDS rt-PA Stroke Study dataset was used to compare baseline to 2-hour NIH Stroke Scale scores (NIHSSS). We calculated baseline NIHSSS - 2hr NIHSSS (positive = improvement [IMP], negative = worsening). Definitions of RISS were raw change in NIHSSS (≥ 4 point IMP) and percent change in NIHSSS (≥ 25% IMP and ≥ 50% IMP). Chi-square and multiple logistic regression modeling were used to assess the association of RISS with outcomes measures. Discharge disposition included: home; relative/friend; rehabilitation; nursing home; death; other. CT lesion volume was based on the 3-month CT scan as previously calculated as a pre-specified secondary outcome of the 2 trials.
Results:
In the 624 subjects, RISS frequency depended on definition used. Frequencies (all %s) of RISS compared to no-RISS who were discharged Home were 55 vs. 30 for ≥ 4 point IMP, 64 vs. 23 for ≥ 25% IMP, and 78 vs. 30 for ≥ 50% IMP. Frequencies for Discharge to Rehabilitation (RISS vs. no-RISS) were: 1 vs. 36, 14 vs. 41, and 10 vs. 36. Nursing Home discharge frequencies were: 5 vs. 11, 4 vs. 12, and 1 vs. 11. Across all definitions of RISS there was a significant difference in discharge status favoring RISS (all p values < 0.001). Three-month CT lesion volumes (cm3): for RISS ≥ 4 point IMP were: 7.51 [95% Confidence Interval (CI): 1.52, 12.34] vs. no-RISS 19.95 (CI: 2.71, 26.42); for RISS ≥ 25%: 4.64 (CI: 1.07, 7.41) vs. no-RISS 25.96 (CI: 2.99, 33.96); for RISS ≥ 50% IMP: 3.14 (CI: 0.44, 6.36) vs. no-RISS 19.75 (CI: 2.73, 25.50). All p values <0.001.There were no statistically significant rt-PA treatment interactions for CT volume (lowest p-value 0.28) and for discharge status (lowest p-value 0.13).
Conclusions:
Post hoc exploratory analyses suggest that based on all definitions of RISS used, those patients with RISS were consistently and significantly discharged to a more favorable location than those without RISS. These findings were also consonant with CT lesion volumes at 3 months being significantly smaller for each definition of RISS vs. no RISS. However, while patients with RISS do better in these exploratory outcomes, they still commonly have evidence of cerebral infarction and approximately 2 of 3 with ≥ 4 point IMP and 1 in 5 with at least 50% IMP are not discharged home.
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