Lack of improvement 24 hours after stroke treatment associated with poor outcome or death at 3 months

Stroke patients who show little improvement in the first 24 hours after receiving thrombolytic (clot-dissolving) therapy are more likely to have poor outcomes or death at three months, according to a study in the October 20 JAMA. Several factors, including elevated blood glucose levels and time to treatment were predictors of lack of improvement.

According to background information in the article, the focus of thrombolytic therapy in acute stroke has been on favorable outcome at 3 months. Few studies have analyzed outcome at 24 hours. Identifying predictors of lack of improvement could improve understanding of the clinical factors that influence the recovery and clinical response to alteplase (clot-dissolving drug). This could help predict poor outcome earlier (24 hours after receiving alteplase) than at 3 months and would have important implications for clinical management and for discharge planning.

Gustavo Saposnik, M.D., of the University of Western Ontario, London, Ontario, Canada and colleagues examined predictors of lack of improvement at 24 hours after receiving alteplase and their relationship with poor outcome at 3 months. The study included 216 acute stroke patients who received alteplase and were admitted to a university hospital from January 1999 to March 2003. Participants were recruited from two academic centers in a major city in Ontario and 33 affiliated hospitals from 7 counties.

The researchers found that 111 (51.4 percent) of the patients had a lack of improvement at 24 hours. After adjusting for age, sex, and stroke severity, independent predictors of lack of improvement included elevated glucose level on admission (nearly 3 times greater risk); cerebral cortex involvement (2.6 times increased risk), and time to treatment. At three months, 43 patients (20.2 percent) had died; of the 170 survivors, 75 patients (44 percent) had poor outcomes. After adjusting for age, sex, and stroke severity, lack of improvement at 24 hours was an independent predictor of poor outcome (nearly 13 times more likely) and death (7.5 times more likely). Patients with a lack of improvement had longer lengths of hospitalization (14.5 vs. 9.6 days).

“Our study adds a useful perspective concerning early prediction of outcome by introducing a clinical variable (lack of improvement) that can be easily measured. Its recognition can contribute to the management of patients with stroke after thrombolytic therapy with alteplase in terms of early prediction of outcome,” the authors write.