Initial Stroke Severity Is the Major Outcome Predictor for Patients Who Do Not Receive Intravenous Thrombolysis due to Mild or Rapidly Improving Symptoms

Intravenous tissue plasminogen activator thrombolysis for stroke is still under use. A substantial proportion of excluded patients for mild or improving symptoms are dependent at discharge. We prospectively recruited 49 patients who did not receive thrombolysis because of mild or improving symptoms. 32 had favorable outcome (mRS ≤ 2) and 17 had unfavorable outcome (mRS > 2) at discharge. Comparisons were made between the two groups. Age was older (72.5 ± 10.0 versus 64.7 ± 13.2 years, P = 0.037), and initial National Institutes of Health Stroke Scale (NIHSS) score (5.7 ± 4.0 versus 2.2 ± 2.1, P < 0.001) was higher in the unfavorable group. Diastolic blood pressure was higher in the favorable group (98 ± 15 versus 86 ± 18 mmHg; P = 0.018). Atrial fibrillation (3.1 versus 23.5%; P = 0.043) and ipsilateral artery stenosis (21.9 versus 58.8%; P = 0.012) were more frequently found in the unfavorable group. Percentage of patients excluded from thrombolysis due to improving symptoms was higher in the unfavorable group (40.6 versus 82.4%; P = 0.005). Initial NIHSS score, but not other factors, was identified by logistic regression analysis as a major independent predictor for unfavorable outcome (OR 1.44; 95%CI, 1.03–2.02).

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Abstract 2808: The Prognosis of Intravenous Thrombolysis with Alteplase Relate to Site of Cerebral Artery Occlusion

Stroke ◽

10.1161/str.43.suppl_1.a2808 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Takao Kanzawa ◽

Ban Mihara ◽

Tomo horikoshi

Keyword(s):

Independent Predictor ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

National Institutes Of Health ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Cerebral Artery Occlusion ◽

Mean Time ◽

Time Form ◽

Iv Tpa

Purpose: The objective of this study was to determine whether the arterial obstruction site is predictive of clinical outcomes in patients receiving intravenous tissue plasminogen activator (IV tPA). Methods: In a retrospective analysis of our stroke database between Nov. 2005 and May. 2011, we identified 91 consecutive patients who were treated with IV tPA within 3 hours after symptom onset of a stroke in the distribution of a documented ICA, proximal M1, distal M1, or M2/M3 occlusion by Magnetic resonance angiography. We analyzed the rate of favorable outcomes at 3 months (modified Rankin Scale 0 or 1) at various occlusion sites, and determined predictors of favorable outcomes. Results: 91 consecutive patients were treated (mean age, 71 +/- 11 yr; 40.9% were women). Median baseline National Institutes of Health Stroke Scale score (NIHSS) was 10 (range, 4 to 32) and mean time form onset to IV tPA was 128+/- 33 minutes. Favorable outcomes were achieved in 55.6% and significantly correlated with age, basal NIHSS and MRI ASPECT score. Based on the occlusion site, M2/M3 occlusion had an OR of 6.4 for favorable outcomes (83.7%, 95% CI: 2.2 to 19.2, P 0.0006), whereas the odds for proximal M1 occlusion was 0.163 (25.9%, 95% CI: 0.059 to 0.447, P 0.0004), ICA occlusion was 0.378 (23.0%, 95% CI: 0.138 to 1.036, P 0.01). After adjusting for age, sex, baseline NIHSS, and MRI ASPECT score, M2/M3 occlusion occlusion were an independent predictor to achieve favorable outcomes (OR: 9.203, 95% CI: 1.896 to 45.443, P 0.006). Conclusions: Clinical outcome in IV tPA depends on the site of occlusion. This is important to make reasonable decisions for identifying which patients benefit in IV tPA and combined IV tPA/ interventional approach.

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Thrombolytic treatment in stroke mimic, inevitable but fortunately safe: An observational study from Iran

Iranian Journal of Neurology ◽

10.18502/ijnl.v18i4.2188 ◽

2020 ◽

Author(s):

Sara Esmaeili ◽

Motahareh Afrakhteh ◽

Maryam Bahadori ◽

Seyedeh Fahimeh Shojaei ◽

Rezan Ashayeri ◽

...

Keyword(s):

Alcohol Intoxication ◽

Intravenous Thrombolysis ◽

Treatment Decision ◽

National Institutes Of Health ◽

Nihss Score ◽

Number Of Patients ◽

Acute Cerebral Ischemia ◽

Tissue Plasminogen ◽

Baseline Characteristics ◽

Stroke Mimic

Background: A number of patients with symptoms of acute cerebral ischemia may have other causes called stroke mimics (SM). The prevalence of SM can be as high as 31% in some reports, and these patients are potentially at the risk of intravenous thrombolysis (IVT) therapy and its complications. This study was designed to determine the prevalence of our center’s SM (Firoozgar Hospital) among patients who received IVT, their baseline characteristics, final diagnoses, and outcomes. Methods: We reviewed the medical records of all patients who received IVT between June 2015 and May 2018. The following variables were collected: demographic characteristics, past medical history, onset-to-needle (OTN) time, door-to-needle (DTN) time, National Institutes of Health Stroke Scale (NIHSS) score at admission, brain imaging, and all paraclinic findings. Functional outcome at discharge based on modified Rankin Scale (mRS) was also assessed. Results: 10 out of 165 (6.0%) patients including 8 men and 4 women were finally diagnosed with SM. The median age and NIHSS score at presentation were 60 years and 7, respectively. Final diagnoses were seizure (n = 6), hemiplegic migraine (n = 2), conversion (n = 1), and alcohol intoxication (n = 1). All patients were discharged with a mRS score of 0 and 1 without experiencing any thrombolytic adverse effects. Conclusion: None of the patients with SM experienced any adverse effect of tissue plasminogen activator (tPA) including hemorrhage and all of them reached good mRS score. This shows that tPA is generally safe and the risk of treating patients with SM is very low and making a vital treatment decision may outweigh the risk of neglected cases in a time-sensitive setting.

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Outcome of multimodal MRI-guided intravenous thrombolysis in patients with stroke with unknown time of onset

Stroke and Vascular Neurology ◽

10.1136/svn-2018-000151 ◽

2019 ◽

Vol 4 (1) ◽

pp. 3-7 ◽

Cited By ~ 1

Author(s):

Jie Zhao ◽

Hongmei Zhao ◽

Runtao Li ◽

Jiangtao Li ◽

Chang Liu ◽

...

Keyword(s):

Arterial Occlusion ◽

Intravenous Thrombolysis ◽

National Institutes Of Health ◽

Control Group ◽

Nihss Score ◽

Intravenous Tissue Plasminogen Activator ◽

Multimodal Mri ◽

The Difference ◽

Data Elements ◽

Treatment Window

ObjectiveIntravenous tissue plasminogen activator (tPA) is the standard therapy for patients with acute ischaemic stroke (AIS) within 4.5 hours of onset. Recent trials have expanded the endovascular treatment window to 24 hours. We investigated the efficacy and safety of using multimodal MRI to guide intravenous tPA treatment for patients with AIS of unknown time of onset (UTO).MethodsData on patients with AIS with UTO and within 4.5 hours of onset were reviewed. Data elements collected and analysed included: demographics, National Institutes of Health Stroke Scale (NIHSS) score at baseline and 2 hours, 24 hours, 7 days after thrombolysis and before discharge, the modified Rankin Scale (mRS) score at 3 months after discharge, imaging findings and any adverse event.ResultsForty-two patients with UTO and 62 in control group treated within 4.5 hours of onset were treated with intravenous tPA. The NIHSS scores after thrombolysis and/or before discharge in UTO group were significantly improved compared with the baseline (p<0.05). Between the two groups, no significant differences in NIHSS score were observed (p>0.05). Utilising the non-inferiority test, to compare mRS scores (0–2) at 3 months between the two groups, the difference was 5.2% (92% CI, OR 0.196). Patients in the UTO group had mRS scores of 0-2, which were non-inferior to the control group. Their incidence of adverse events was similar.ConclusionsUtilising multimodal MRI to guide intravenous only thrombolysis for patients with AIS with UTO was safe and effective. In those patients with AIS between 6 and 24 hours of time of onset but without large arterial occlusion, intravenous thrombolysis could be considered an option.

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The Routine Follow-up Head CT: Is it Still a Necessary Step in the Thrombolysis Pathway?

Neurocritical Care ◽

10.1007/s12028-021-01348-4 ◽

2021 ◽

Author(s):

Edward J. Llinas ◽

Alexandra Max ◽

Sheena Khan ◽

Elisabeth B. Marsh

Keyword(s):

Ct Scan ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

National Institutes Of Health ◽

Stroke Severity ◽

Head Ct ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Early Imaging

Abstract Background The 24-h head computed tomography (CT) scan following intravenous tissue plasminogen activator or mechanical thrombectomy (MT) is currently part of most acute stroke protocols. However, as evidence emerges regarding who is at highest risk for treatment complications, the utility of routine neuroimaging for all patients has become less clear. Methods Four hundred seventy-five patients presenting with acute ischemic stroke to Johns Hopkins Bayview Medical Center between 2004 and 2018 and treated with intravenous tissue plasminogen activator and/or MT were evaluated. Neuroimaging performed during the first 48 h of hospitalization was reviewed for edema, hemorrhagic transformation (HT), or other findings altering management. Early imaging (< 24 h), performed for neurologic deterioration, was compared with imaging performed per protocol (24 ± 6 h). Factors predictive of radiographically and clinically significant findings on per-protocol imaging were determined. Results One hundred fifty-three patients (32%) underwent early imaging. These patients generally had more severe strokes. HT was found in 15% of cases. For the remaining patients (n = 322), imaging at 24 h impacted acute management for only 24 patients: resulting in emergent hemicraniectomy in 1 (0.3%) and leading to additional imaging to monitor asymptomatic HT or edema in 23 (7.1%). Advanced age, higher stroke severity, MT, and atrial fibrillation were associated with significant findings on the 24-h CT scan. Only 2 of the 24 patients had an initial National Institutes of Health Stroke Scale score of < 7. Conclusions The 24-h head CT scan does not change management for most patients, particularly those with low National Institutes of Health Stroke Scale scores who do not undergo MT. Consideration should be given to removing routine follow-up imaging from postthrombolysis protocols in favor of an examination-based approach.

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Hyperglycemia during Ischemia Rapidly Accelerates Brain Damage in Stroke Patients Treated with tPA

Journal of Cerebral Blood Flow & Metabolism ◽

10.1038/sj.jcbfm.9600460 ◽

2007 ◽

Vol 27 (9) ◽

pp. 1616-1622 ◽

Cited By ~ 64

Author(s):

Marc Ribo ◽

Carlos A Molina ◽

Pilar Delgado ◽

Marta Rubiera ◽

Raquel Delgado-Mederos ◽

...

Keyword(s):

Brain Damage ◽

Independent Predictor ◽

Characteristic Curve ◽

Artery Occlusion ◽

National Institutes Of Health ◽

Occlusion Time ◽

Poor Outcome ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Lesion Extension

To evaluate impact of glucose burden on diffusion-weighted imaging (DWI)-lesion evolution according to ischemia duration in stroke. We studied 47 patients with transcranial Doppler (TCD)-documented artery occlusion treated with intravenous tissue plasminogen activator. Hyperglycemia (HG) was defined as glucose > 140 mg/dL. A subcutaneous device continuously monitored glucose during 24 h. Magnetic resonance imaging was performed pretreatment (1) and at 24 to 36 h (2) in 30 patients. We measured initial PWI lesion (PW1) and DWI growth: DW2–DW1 (DWg). Serial TCD during 24 h determined occlusion time (OT). National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and 48 h. Poor short-term clinical course defined as <50% recovery of initial NIHSS. Baseline NIHSS was 18. On admission 10 patients (21.3%) were hyperglycemic and presented similar NIHSS, DW1, and PW1 lesion extension as those without HG. During monitoring 24 patients (51%) had HG, 21 (45%) of them during OT (median OT 12 h). Median 48 h-NIHSS was 10; 15 patients presented poor outcome. 48 h-NIHSS was higher in patients with HG during OT (15 versus 3; P < 0.001). Patients with favorable outcome had shorter OT (8.4 versus 17.4 h; P < 0.001). However, the only independent predictor of poor outcome was HG during OT (OR: 20.3; 95% CI: 3.77 to 108.8; P < 0.001). At 24 h mean DWg was 52 cm3. A receiver operating characteristic curve identified DWg > 14 cm3 best predictor of poor outcome (sensitivity, 85.7%; specificity, 75%). Total OT ( P = 0.007) and HG during OT ( P = 0.01) showed the strongest correlation with DWg. DWI lesion grew 2.7 times faster in patients with HG than without HG during OT (1.73 versus 4.63 cm3/h of occlusion; P = 0.07). In a regression model the only independent predictor of DWg was HG during OT (OR: 10.83; 95% CI: 1.96 to 59.83; P = 0.006). Hyperglycemia, especially during OT, has a powerful deleterious effect after stroke accelerating brain damage.

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Comparison of outcome of patients with acute minor ischaemic stroke treated with intravenous t-PA, DAPT or aspirin

Stroke and Vascular Neurology ◽

10.1136/svn-2019-000319 ◽

2020 ◽

pp. svn-2019-000319

Author(s):

Peng Wang ◽

Mengyuan Zhou ◽

Yuesong Pan ◽

Xia Meng ◽

Xingquan Zhao ◽

...

Keyword(s):

Functional Outcome ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

National Institutes Of Health ◽

Minor Stroke ◽

Post Hoc Analysis ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Ischemic Attack ◽

Post Hoc

BackgroundWhether to treat minor stroke with intravenous tissue plasminogen activator (t-PA) treatment or antiplatelet therapy is a dilemma. Our study aimed to explore whether intravenous t-PA treatment, dual antiplatelet therapy (DAPT) and aspirin have different efficacies on outcomes in patients with minor stroke.MethodsA post hoc analysis of patients with acute minor stroke treated with intravenous t-PA within 4.5 hours from a nationwide multicentric electronic medical record and patients with acute minor stroke treated with DAPT and aspirin from the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack Database. Minor stroke was defined by a score of 0–3 on the National Institutes of Health Stroke Scale at randomisation. Favourable functional outcome (defined as modified Rankin Scale (mRS) score of 0–1 or 0–2 at 3 months).ResultsCompared with those treated with intravenous t-PA, no significant association with 3-month favourable functional outcome (defined as mRS score of 0–1) was found neither in patients treated with aspirin (87.8% vs 89.4%; OR, 0.83; 95% CI, 0.46 to 1.50; p=0.53) nor those treated with DAPT (87.4% vs 89.4%; OR, 0.84; 95% CI, 0.46 to 1.52; p=0.56). Similar results were observed for the favourable functional outcome defined as mRS score of 0–2 at 3 months.ConclusionsIn our study, no significant advantage of intravenous t-PA over DAPT or aspirin was found. Due to insufficient sample size, our study is probably unable to draw such a conclusion that that intravenous t-PA was superior or non-superior to DAPT.

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Treating ischaemic stroke with intravenous tPA beyond 4.5 hours under the guidance of a MRI DWI/T2WI mismatch was safe and effective

Stroke and Vascular Neurology ◽

10.1136/svn-2018-000186 ◽

2019 ◽

Vol 4 (1) ◽

pp. 8-13 ◽

Cited By ~ 1

Author(s):

Qing-ke Bai ◽

Zhen-guo Zhao ◽

Lian-jun Lu ◽

Jian Shen ◽

Jian-ying Zhang ◽

...

Keyword(s):

Ischaemic Stroke ◽

Contrast Material ◽

Final Analysis ◽

National Institutes Of Health ◽

Haemorrhagic Transformation ◽

Intravenous Tissue Plasminogen Activator ◽

Hyperintense Signal ◽

Rapid Sequence ◽

Tissue Plasminogen ◽

Sequence Study

PurposeClinical trials have provided evidence that treating patients with acute ischaemic stroke (AIS) beyond 4.5 hours was feasible. Among them using MRI diffusion-weighted imaging/fluid attenuation inversion response (DWI/FLAIR) mismatch to guide intravenous tissue plasminogen activator (tPA) was successful. Our study explored the outcome and safety of using DWI/T2-weighted imaging (T2WI) mismatch to guide intravenous tPA therapy for patients with AIS between 4.5 hours and 12 hours of onset.MethodThis was a retrospective study. Records of 1462 AIS patients with the time of onset of <12 hours were reviewed. Those had MRI rapid sequence study and had hyperintense signal on DWI but normal T2WI and received intravenous tPA up to 12 hours of onset were included in the analysis. Their demographics, risk factors, post-tPA complications, National Institutes of Health Stroke Scale (NIHSS) scores and outcome were recorded and analyse. χ2 was used to compare the intergroup variables. SAS was used to perform statistical calculation. A p<0.05 was considered statistically significant.ResultsOf 1462 identified, 601 (41%) patients were entered into the final analysis. Among them, 327 (54%) had intravenous tPA within 4.5 hours of onset and 274 (46%) were treated between 4.5–12 hours. After intravenous tPA, 426 cases (71%) had >4 pints of improvement on NIHSS score within 24 hours. Postintravenous tPA, 32 (5.32%) cases had haemorrhagic transformation. 26 (4.33%) were asymptomatic ICH and 4 (0.67%) died. At 90 days, 523 (87%) achieved a modified Rankin scale of 0–2.ConclusionUsing MRI DWI/T2WI mismatch to identify patients with AIS for intravenous tPA between 4.5 hours and 12 hours was safe and effective. The outcome was similar to those used DWI/PWI or DWI/FLAIR mismatch as the screening tool. However, obtaining DWI/T2WI was faster and avoided the need of contrast material.

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Abstract 145: Outcome in Patients with Minor Stroke: The Effect of Itemized NIHSS Score Subsets

Stroke ◽

10.1161/str.46.suppl_1.145 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Shadi Yaghi ◽

Joshua Z Willey ◽

Howard Andrews ◽

Amelia K Boehme ◽

Leigh Quarles ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Minor Stroke ◽

Motor Deficits ◽

Stroke Severity ◽

Nihss Score ◽

Discharge Disposition ◽

Discharge Home ◽

Dichotomous Variable ◽

Secondary Analyses ◽

Multivariable Regression

Background: The use of the National Insitutes of Health Stroke Scale (NIHSS) to assess stroke severity in minor stroke is controversial. We hypothesized that patients with cortical signs on the itemized NIHSS subsets (neglect, visual, or language) will have a worse outcome than those without. Methods: Data was retrieved from the Columbia SPOTRIAS dataset. All patients with NIHSS between 0 and 5 within 12 hours from symptom onset who were not treated with intravenous thrombolysis were included. Patients were followed prospectively as part of the “Stroke Warning Information and Faster Treatment” Study. Poor outcome was defined as not being discharged home and analyzed using multivariable logistic regression. The primary predictor was cortical features on the itemized NIHSS. Individual components of the NIHSS score, treated as a dichotomous variable, as well as the admission NIHSS score were assessed in secondary analyses. Results: The sample included 894 patients, of which 162 (18%) were not discharged home. In multivariable regression analysis of baseline demographics, risk factors, median NIHSS, and cortical signs, only mean age (OR = 1.02, P<0.001) and NIHSS score (OR = 1.59, p<0.001) were associated with non-discharge home. In secondary analyses having any score on the following items predicted non-discharge home: Motor (OR = 2.40, p<0.001), LOC (OR = 6.67, p=0.004), and Ataxia (OR = 3.21, p<0.001). Other items from the NIHSS were not associated with discharge disposition. Motor deficits (AUC 0.623) appeared to be more predictive of discharge outcome than ataxia (AUC 0.569) and LOC deficits (AUC 0.517). In addition, the admission NIHSS had a fair correlation with discharge outcome (AUC 0.683). Conclusion: Deficits in LOC, motor weakness, and ataxia predict discharge outcome in patients with mild stroke, with the motor score being the most influential component. This may potentially alter treatment decisions in this population. The fair correlation between NIHSS score and discharge outcome suggests that certain factors not captured by the NIHSS score may contribute to discharge outcome in this patient population.

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Safety of Glycoprotein IIb-IIIa Inhibitors Used in Stroke-Related Treatment: A Systematic Review and Meta-Analysis

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029620942594 ◽

2020 ◽

Vol 26 ◽

pp. 107602962094259

Author(s):

Xiaolin Zhu ◽

Genmao Cao

Keyword(s):

Intracranial Hemorrhage ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Recombinant Tissue Plasminogen Activator ◽

Antiplatelet Agents ◽

National Institutes Of Health ◽

Randomized Controlled ◽

Tissue Plasminogen ◽

Treatment Administration ◽

Symptomatic Intracranial Hemorrhage

Background: Endovascular therapy and intravenous thrombolysis with recombinant tissue plasminogen activator are the 2 most recommended treatments for acute ischemic stroke (AIS). Glycoprotein (GP) IIb-IIIa inhibitors are short-acting selective reversible antiplatelet agents that emerged as promising therapeutic agents for AIS about 10 years ago. Given the unclear safety profile and application coverage of GP inhibitors, we conducted this meta-analysis to explore the same. Methods: We used GP IIb-IIIa inhibitors, intracranial hemorrhage, and mortality as the key words on Medline, Web of Science, and the Embase databases. Randomized controlled trials, prospective literatures, and retrospective studies in English published between 1990 and 2020 were screened. The outcomes were relative risk (RR) of death and 90-day intracerebral hemorrhage (ICH). We pooled the results in 2 categories and conducted a subgroup analysis stratified by different drugs. The choice of the effects model depended on the value of I 2. Results: In all, 3700 patients from 20 studies were included. No GP IIb-IIIa inhibitors were found to have a remarkable influence on the ICH rate. The RR values of symptomatic ICH for abciximab and eptifibatide were 4.26 (1.89, 9.59) and 0.17 (0.04, 0.69), respectively. Both tirofiban and abciximab could decrease the mortality rate within 90 days. Age > 70 years, National Institutes of Health Stroke Scale > 15, and overall dose > 10 mg are risk factors for ICH events with tirofiban usage. Thrombectomy combined with tirofiban was safe for arterial reocclusion prevention. Conclusions: In stroke-related treatment, administration of GP IIb-IIIa inhibitors could be safe, but care should be taken regarding drug species and doses. Abciximab can increase the risk of symptomatic intracranial hemorrhage. Tirofiban and eptifibatide can be considered safe in low doses. Suitable patients should be selected using strict criteria.

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Who Is Classified as Untestable on Brief Cognitive Screens in an Acute Stroke Setting?

Diagnostics ◽

10.3390/diagnostics9030095 ◽

2019 ◽

Vol 9 (3) ◽

pp. 95 ◽

Cited By ~ 3

Author(s):

Emma Elliott ◽

Bogna A. Drozdowska ◽

Martin Taylor-Rowan ◽

Robert C. Shaw ◽

Gillian Cuthbertson ◽

...

Keyword(s):

Cognitive Assessment ◽

Odds Ratio ◽

National Institutes Of Health ◽

Screening Tests ◽

Stroke Severity ◽

Modified Rankin Scale ◽

Cognitive Screening ◽

Dementia Diagnosis ◽

Nihss Score ◽

Test Completion

Full completion of cognitive screening tests can be problematic in the context of a stroke. Our aim was to examine the completion of various brief cognitive screens and explore reasons for untestability. Data were collected from consecutive stroke admissions (May 2016–August 2018). The cognitive assessment was attempted during the first week of admission. Patients were classified as partially untestable (≥1 test item was incomplete) and fully untestable (where assessment was not attempted, and/or no questions answered). We assessed univariate and multivariate associations of test completion with: age (years), sex, stroke severity (National Institutes of Health Stroke Scale (NIHSS)), stroke classification, pre-morbid disability (modified Rankin Scale (mRS)), previous stroke and previous dementia diagnosis. Of 703 patients admitted (mean age: 69.4), 119 (17%) were classified as fully untestable and 58 (8%) were partially untestable. The 4A-test had 100% completion and the clock-draw task had the lowest completion (533/703, 76%). Independent associations with fully untestable status had a higher NIHSS score (odds ratio (OR): 1.18, 95% CI: 1.11–1.26), higher pre-morbid mRS (OR: 1.28, 95% CI: 1.02–1.60) and pre-stroke dementia (OR: 3.35, 95% CI: 1.53–7.32). Overall, a quarter of patients were classified as untestable on the cognitive assessment, with test incompletion related to stroke and non-stroke factors. Clinicians and researchers would benefit from guidance on how to make the best use of incomplete test data.

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