Background: A higher percentage of acute ischemic stroke patients resort to care withdrawal after standardized treatments have been instituted.
Objective: We aimed at identifying the factors responsible for care withdrawal among patients with acute ischemic stroke receiving various standardized treatment modalities in a clinical trial setting.
Design and Methods: We analyzed data from Interventional Management of Stroke (IMS) III; a multicenter, double-blinded, randomized clinical trial. The patients who had resorted to care withdrawal during the course of trial were identified and divided into three groups based on the type of acute stroke treatment: IV-thrombolysis only, IA-thrombectomy only, and combined IA-thrombectomy with IA-thrombolysis. The three groups were compared for their baseline characteristics and major outcomes such as neurologic deterioration within 24-hours of randomization, hemorrhagic complications, and length of hospital stay. Bonferroni adjusted p-value of 0.016 was considered significant.
Results: Out of 123 patients who had withdrawal of care in the IMS-III trial, 47 (38.2%) received IV-thrombolysis only, 25 (20.3) received IA-thrombectomy only, and 51 (41.5) received combined IA-thrombectomy and IA-thrombolysis. The three groups were similar for age, gender, baseline NIHSS score, stroke etiology, time from stroke onset to randomization, and status prior to stroke. Patients who received IV-thrombolysis only had significantly more mother ship transfers followed by IA-thrombectomy only and combined treatment groups (89.4 vs 68.0 vs 76.5; p=0.006). The combined treatment group had significantly greater rate of asymptomatic intracranial hemorrhage (ICH) followed by IA-thrombectomy only and IV-thrombolysis only treatment arms (41.2% vs 28% vs. 14.9%; p=0.015). Higher rates of patients undergoing IV-thrombolysis only treatment resorted to full palliative care as compared to the other two groups (p=0.07). The three groups did not differ in their rates of neurologic deterioration and length of hospital stay (p=0.84 and p=0.42 respectively).
Conclusions: Asymptomatic ICH is a major determinant of care withdrawal after treatment of acute ischemic stroke with combined IA-thrombolysis and IA-thrombectomy.