Introduction: National clinical guidelines in England and Wales recommend that intravenous thrombolysis is provided regardless of pre-stroke disability, but thrombolysis trials have included very few patients with a modified Rankin scale (mRS) score of more than 2. We therefore analysed data from the national stroke register of England and Wales of over 100,000 records to determine the safety and outcomes of thrombolysis in patients with varying levels of pre-stroke disability.
Methods: Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischemic stroke treated in all hospitals in England and Wales from April 2013-March 2015.
Results: Of 128826 adults with acute ischemic stroke admitted to 202 hospitals, 23850 (18.5%) were dependent in some activities of daily living before stroke (mRS of more than 2). Of these, 1926 (8.1%) were treated with intravenous alteplase (iv-tPA).
Of the patients with an mRS greater than 2 who were treated with iv-tPA, 1239 (64.3%) were female, 120 (6.2%) had an onset whilst already an inpatient, and 1395 (72.4%) were fully conscious upon arrival at hospital. The median age was 84 years (IQR 78-89); the median NIHSS score 15 (IQR 9-21).
Of the 1320 patients (68.5%) with a fully completed NIHSS at arrival and at 24h after thrombolysis, the median change in NIHSS was a 3 point improvement (IQR 0-7).
A total of 214 patients (11.1%) had complications from thrombolysis; 104 (5.4%) had symptomatic intracranial hemorrhage, 10 (0.5%) had angioedema, 21 (1.1%) had extracranial bleeds and 82 (4.3%) had some other type of thrombolysis complication.
Inpatient case fatality rate was 29.2%, and 10.2% were newly institutionalised in a care home (14.4% of those discharged alive).
Conclusions: Patients treated with iv-tPA who were not independent before stroke have similar rates of complications as reported for independent patients in national registries and clinical trials. However stroke for patients with pre-stroke disability carries a high risk of mortality and a high proportion of survivors are discharged to long term care for the first time.