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Tissue Plasminogen Activator Does Not Cause Symptomatic Haemorrhage in Stroke Mimics: Presented at ISC

By Lexa W. Lee

NEW ORLEANS -- February 26, 2008 -- Use of IV tissue plasminogen activator (tPA) does not appear to put stroke mimics at increased risk of symptomatic haemorrhage, according to a study presented here at the International Stroke Conference (ISC) 2008.

Efforts to increase the availability of IV thrombolysis and to shorten the time to delivery of IV tPA are known to increase the possibility that stroke mimics will be given tPA therapy. Limited data exist, however, regarding the use of thrombolysis in patients erroneously diagnosed in the emergency department (ED) as having ischaemic stroke.

Researchers led by Georgios Tsivgoulis, Neurologist, Barrow Neurological Institute, Phoenix, Arizona, conducted a retrospective study to determine the safety of thrombolysis in stroke mimics and to describe outcomes in this group of patients.

They used a cohort design to analyse stroke registry data from consecutive patients treated for ischaemic stroke with IV tPA according to standard indications in their ED from 2002 to 2005. National Institutes of Health Stroke Scale (NIHSS) scores and modified Rankin Scores (mRS) were documented.

Ischaemic lesions were documented on magnetic resonance imaging scans performed routinely as part of diagnostic workup 24 to 72 hours after symptom onset.

Decision to administer thrombolytic treatment was based on the baseline computed tomography scan. The initial diagnosis of stroke in ED was compared with the final diagnosis at hospital discharge. The identification of stroke mimics was based on the absence of ischaemic lesions on diffusion-weighted imaging sequences in addition to the final diagnosis. Symptomatic intracerebral haemorrhage (sICH) was diagnosed based on brain imaging evidence in addition to an increase in NIHSS score of at least 4 points.

A total of 216 men and 165 women (mean age 66 years) with ischaemic stroke received IV thrombolysis. Misdiagnosis of ischaemic stroke was documented in 8% of cases (95% confidence interval, 5.4%-10.9%). The most common final diagnoses in stroke mimics treated with tPA were conversion disorder (35%) and complicated migraine (19%).

Stroke mimics were younger (mean age 56 vs 67 years) and had milder stroke severity compared with patients with confirmed acute ischaemic stroke (NIHSS 5 vs 10 points, interquartile range (IQR) 5 vs 8 points; P < .001).

No sICH occurred in stroke mimics. All stroke mimics were functionally independent at hospital discharge (mRS: 0-1) and they had shorter duration of hospital stay compared with patients who had confirmed acute ischaemic stroke (median 3 vs 5 days, IQR 2 vs 4 days; P > .001).

The researchers concluded that symptomatic haemorrhagic complications did not occur in stroke mimics treated with IV tPA at their centre. Stroke mimics also had a shorter length of hospital stay and were functionally independent at hospital discharge. The researchers noted that definitive conclusions regarding safety of thrombolysis cannot be drawn with statistical confidence due to the limited sample size.


[Presentation title: Safety of Thrombolysis in Stroke Mimics. Abstract P102]

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