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

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.