Background: Acute changes in the NIHSS are common in patients with large artery ischemic stroke. Unfortunately, even small improvements in the NIHSS may be viewed as a reason not to treat with intravenous tPA (IVtPA) among emergency practitioners with less alteplase experience. We sought to quantify outcome of patients denied IVtPA due to NIHSS score change, in an effort to improve future treatment decisions by our emergency practitioners.
Methods: A retrospective observational study was conducted using a cohort of acute ischemic stroke patients presenting to our community hospital in southern California between January 1, 2010 and December 31, 2013. All patients in the cohort were denied IVtPA treatment due to perceived "rapidly improving symptoms" suggestive of TIA. The cohort was assembled from our Get with the Guidelines database, with all data verified to validate data accuracy. Descriptive data as well as the NIHSS score prompting the decision against IVtPA, both NIHSS and mRS at discharge, and length of stay (LOS) were entered and analyzed using SPSS.
Results: 50 patients were identified for IVtPA non-treatment due to an NIHSS change; patients were 60% male and averaged 71.8 + 11.1 years age. Pre-morbid mRS median was 0. NIHSS median at time of reason not to treat was 3.5. While admission and discharge NIHSS were similar, discharge median mRS was significantly worse than premorbid mRS at 2 (p<0.001), with the majority of patients discharging disabled from their stroke. Length of stay averaged 3.4 + 2.5 days and did not differ by age, gender or stroke subtype, but was positively correlated with discharge NIHSS scores (r=.627; p<0.001) which accounted for 39% of the variance.
Conclusion: Change in NIHSS score without total disability resolution is a poor predictor of neurologic outcome after stroke. Regularly sharing discharge outcomes of patients according to IVtPA treatment status may play an important role in changing treatment decision making behaviors among reluctant alteplase users.