Intravenous thrombolysis in young stroke patients: Results from the SITS-ISTR

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Abstract

Objective:

To assess safety and efficacy of thrombolysis in 18- to 50-year-old patients compared to those aged 51 to 80 years recorded in the Safe Implementation of Thrombolysis in Stroke–International Stroke Thrombolysis Register (SITS-ISTR).

Methods:

A total of 27,671 patients aged 18–80 years treated with IV alteplase within 4.5 hours of symptom onset were enrolled in SITS-ISTR between 2002 and 2010. Main outcome measures were symptomatic intracerebral hemorrhage (SICH; deterioration of ≥4 points on the NIH Stroke Scale [NIHSS] within 24 hours and type 2 parenchymal hematoma), mortality, and functional independence (modified Rankin Scale [mRS] 0–2) at 3 months.

Results:

In the 3,246 (11.7%) patients aged 18–50, SICH occurred in 0.6% vs 1.9% in those aged 51–80 (adjusted odds ratio [aOR] 0.53; 95% confidence interval [CI] 0.31–0.90, p = 0.02). Three-month mortality was 4.9% and 14.4%, respectively (aOR 0.49; 95% CI 0.40–0.60, p < 0.001) and functional independence was 72.1% vs 54.5%, respectively (aOR 1.61; 95% CI 1.43–1.80, p < 0.0001). In multivariable analysis in young patients, baseline systolic blood pressure (SBP) was the only independent factor associated with SICH (p = 0.04). Baseline NIHSS, baseline glucose, and signs of infarction in baseline imaging scan were associated with higher mortality and poorer functional outcome. Male gender, mRS before stroke, and atrial fibrillation (AF) were associated with higher mortality, and age, SBP, and previous stroke were associated with mRS.

Conclusions:

Treatment with IV alteplase is safe in young ischemic stroke patients and they benefit more compared to older patients. We found several factors associated with SICH, mortality, and functional outcome. These can be used to help in the selection of young ischemic stroke patients for thrombolysis.

Classification of evidence:

This study provides Class III evidence that younger patients (18–50 years) with ischemic stroke symptoms treated with IV alteplase have lower morbidity and mortality compared to older patients (51–80 years).

GLOSSARY

AF: atrial fibrillation

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aOR: adjusted odds ratio

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CASES: Canadian Alteplase for Stroke Effectiveness Study

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CI: confidence interval

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DBP: diastolic blood pressure

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ECASS III: European Cooperative Acute Stroke Study III

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mRS: modified Rankin Scale

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NIHSS: NIH Stroke Scale

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NINDS: National Institute of Neurologic Disorders and Stroke

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SBP: systolic blood pressure

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SICH: symptomatic intracerebral hemorrhage

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SITS-ISTR: Safe Implementation of Thrombolysis in Stroke–International Stroke Thrombolysis Register

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SITS-MOST: Safe Implementation of Thrombolysis in Stroke–Monitoring Study

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TOAST: Trial of Org 10172 in Acute Stroke Treatment

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