J Cerebrovasc Endovasc Neurosurg.  2019 Jun;21(2):77-85. 10.7461/jcen.2019.21.2.77.

Long-term Prognosis of Patients Who Contraindicated for Intravenous Thrombolysis in Acute Ischemic Stroke

• Lee BY
• Oh JS
• Yoon SM

• KMID: 2465200
• DOI: http://doi.org/10.7461/jcen.2019.21.2.77

Abstract

BACKGROUND
As intravenous thrombolysis (IVT) has very restricted inclusion criteria, eligible patients of IVT constitute a very small proportion and studies about their mortality are rare. The long-term mortality in a patients with contraindication of ineligible patients of IVT still under the debate. So, we investigated the proportion of patients with contraindication of IVT and the short and long-term mortality of them in AIS on emergency department comparing with the long-term effect of IVT in patients with moderate-to-severe stroke.
METHODS
Using acute stroke assessment indication registry & Health Insurance Review and Assessment Service database, a total of 5,407 patients with NIHSS≥5 were selected from a total of 169 acute stroke care hospital nationwide during October-December 2011 and March-June 2013. We divided AIS patients into two groups: 1) IVT group who received IVT within 4.5 hours, and 2) non-IVT group who did not receive the IVT because of contraindications. And we divided the subgroups according to the reason of contraindication of IVT. The 5-year survival rate of each group was assessed using Kaplan-Meyer survival analysis.
RESULTS
Of the 5,407 patients, a total of 1,027 (19%) patients who received IVT using r-tPA within 4.5 h after onset. Compared with the IVT group, hazard ratios of non-IVT group were 1.33 at 3 months, 1.53 at 1 year and 1.47 at 5 years (p<.001). A total of 4,380 patients did not receive IVT because of the following contraindications to IVT. 1) Time restriction: 3,378 (77.1 %) patients were admitted after 4.5 h following stroke onset, and 144 (3.3%) patients failed to determine the stroke onset time. 2) Mild symptoms:137 (3.1%) patients had rapid improvement or mild stroke on emergency room, 3) Bleeding diathesis or non-adjustable hypertension: 53 (1.2%) patients showed a bleeding tendency or severe hypertension. Compared with the IVT group, the subgroups of non-IVT group showed consistently high mortality during short and long term follow up. Mild symptom and bleeding diathesis or non-adjustable hypertension subgroup in the non-IVT group consistently showed the higher mortality than time restriction subgroup during the short and long-term follow-up (log-rank p<.001). Patients who had rapid improvement or mild stroke on emergency department had the higher mortality than time restriction group in short and long term follow up.
CONCLUSION
The AIS patients with rapid improvement or mild stroke on emergency room had higher mortality than ineligible patients of IVT due to time restriction during the short and long-term follow-up. A further management and special support on emergency department is needed for these patients with initially mild stroke and rapid improvement in AIS to reduce the poor outcome.

Keyword

Stroke; Thrombolytic Therapy; Tissue Plasminogen Activator; Mechanical Thrombectomy; Mortality; Emergency Medical Services

MeSH Terms

Disease Susceptibility
Emergency Medical Services
Emergency Service, Hospital
Follow-Up Studies
Hemorrhage
Humans
Hypertension
Insurance, Health
Mortality
Prognosis*
Stroke*
Survival Rate
Thrombolytic Therapy
Tissue Plasminogen Activator
Tissue Plasminogen Activator

Figure

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  Fig. 1 The 5-year survival rate of acute ischemic stroke patients between IVT group and non-IVT group.IVT: Intravenous thrombolysis

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