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Predictors and Association With Outcome

Gustavo Saposnik, MD; Bryan Young, MD; Brian Silver, MD; Silvia Di Legge, MD; Fiona Webster, MA; Vadim Beletsky, MD; Vivek Jain, MD; Yongchai Nilanont, MD; Vladimir Hachinski, MD

JAMA. 2004;292:1839-1844.

Context  The focus of thrombolytic therapy in acute stroke has been on favorable outcome at 3 months. Few studies have analyzed outcome at 24 hours. An early and reliable prediction of poor outcome has implications for clinical management and discharge planning.

Objective  To evaluate predictors of lack of improvement at 24 hours after receiving alteplase and their relationship with poor outcome at 3 months.

Design, Setting, and Participants  Prospective cohort of consecutive patients with acute stroke who received alteplase and were admitted to a university hospital from January 1999 to March 2003. Participants were recruited from 2 academic centers in a major city in Ontario and 33 affiliated hospitals from 7 counties.

Main Outcome Measures  Lack of improvement defined as a difference between the National Institutes of Health Stroke Scale score at baseline and at 24 hours of 3 points or less. Poor outcome at 3 months defined by a modified Rankin Scale score of 3 to 5 or death.

Results  Among 216 patients with acute stroke who were treated with alteplase, 111 (51.4%) had a lack of improvement at 24 hours. After adjusting for age, sex, and stroke severity, baseline glucose level on admission (odds ratio [OR] 2.89; 95% confidence interval [CI], 1.40-5.99 for a glucose level >144 mg/dL [>8 mmol/L]), cortical involvement (OR, 2.66; 95% CI, 1.36-5.20), and time to treatment (OR, 1.01; 95% CI, 1.0-1.02 for each 1 minute increase in time to treatment) were independent predictors of lack of improvement. At 3 months, 43 patients (20.2%) had died; of the 170 survivors, 75 patients (44%) had poor outcomes. After adjusting for age, sex, and stroke severity, lack of improvement at 24 hours was an independent predictor of poor outcome (OR, 12.9; 95%CI, 5.7-29.6) and death (OR, 7.5; 95% CI, 2.9-19.6). Patients with a lack of improvement had longer lengths of hospitalization (14.5 vs 9.6 days; P = .02).

Conclusions  Among patients with acute stroke treated with thrombolytic therapy, lack of improvement at 24 hours is associated with poor outcome and death at 3 months. Elevated glucose level, time to thrombolytic therapy, and cortical involvement were predictors of lack of improvement.

Author Affiliations: Stroke Program, Department of Clinical Neurological Sciences, London Health Sciences Centre, University of Western Ontario, London (Drs Saposnik, Young, Di Legge, Beletsky, Jain, Nilanont, and Hachinski and Ms Webster); and Department of Neurology, Henry Ford Hospital, Detroit, Mich (Dr Silver).

Corresponding Author: Gustavo Saposnik, MD, Stroke Service, London Health Sciences Centre, University of Western Ontario, 339 Windermere Rd, Office 7-GE5, London, Ontario, Canada N6A 5A5 (gsaposni{at}uwo.ca).

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