title: Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke.
abstract: OBJECTIVE
  Some patients with mild or improving ischemic stroke symptoms do not receive intravenous tissue plasminogen activator (tPA) because they look "too good to treat" (TGT); however, some have poor outcomes.
  
  
  METHODS
  We retrospectively analyzed data from a prospective single-center study between 2002 and 2004. TGT patients were those arriving within 3 hours of symptom onset and not treated with intravenous tPA solely because of mild or improving symptoms.
  
  
  RESULTS
  Of 128 patients presenting within 3 hours, 41 (34%) were not given tPA because of mild or improving stroke. Of the TGT patients, 11 of 41 (27%) died or were not discharged home because of neurological worsening (n=6) or persistent "mild" neurological deficit (n=5). No single variable at presentation was associated with death or lack of home discharge. There were 10 of 41 TGT patients (24%) who had > or =4-point improvement in National Institutes of Health Stroke Scale score before tPA decision; these patients were more likely to have subsequent neurological worsening (relative risk, 4.1, 95% CI, 1.1 to 15.4; P=0.05).
  
  
  CONCLUSIONS
  A substantial minority of patients deemed too good for intravenous tPA were unable to be discharged home. A re-evaluation of the stroke severity criteria for tPA eligibility may be indicated.
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA. eesmith@partners.org
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
authors.forename: Abdul R
authors.initials: AR
authors.lastname: Abdullah
authors.forename: Iva
authors.initials: I
authors.lastname: Petkovska
authors.forename: Eric
authors.initials: E
authors.lastname: Rosenthal
authors.forename: Walter J
authors.initials: WJ
authors.lastname: Koroshetz
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
mesh_terms: D000368:Aged; D000792:Angiography; D015331:Cohort Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D007262:Infusions, Intravenous; D007511:Ischemia / Q000188:drug therapy* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D012044:Regression Analysis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy* / Q000401:mortality; D015912:Thrombolytic Therapy / Q000379:methods; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator