title: Too good to treat? Outcomes in patients not receiving thrombolysis due to mild deficits or rapidly improving symptoms.
abstract: BACKGROUND
  Among ischemic stroke patients arriving within the treatment window, rapidly improving symptoms or having a mild deficit (i.e. too good to treat) is a common reason for exclusion. Several studies have reported poor outcomes in this group. We addressed the question of early neurological deterioration in too good to treat patients in a larger prospective cohort study.
  
  
  METHODS
  Admission and discharge information were collected prospectively in acute stroke patients who presented to the emergency room within three-hours from onset. The primary outcome measure was change in the National Institutes of Health Stroke Scale from baseline to discharge. Secondary outcomes were discharge National Institutes of Health Stroke Scale >4, not being discharged home, and discharge modified Rankin scale.
  
  
  RESULTS
  Of 355 patients who presented within three-hours, 127 (35·8%) had too good to treat listed as the only reason for not receiving thrombolysis, with median admission National Institutes of Health Stroke Scale = 1 (range = 0 to 19). At discharge, seven (5·5%) showed a worsening of National Institutes of Health Stroke Scale ≥1, and nine (7·1%) had a National Institutes of Health Stroke Scale >4. When excluding prior stroke (remaining n = 97), discharge status was even more benign: only five (5·2%) had a discharge National Institutes of Health Stroke Scale >4, and two (2·1%) patients were not discharged home.
  
  
  CONCLUSIONS
  We found that a small proportion of patients deemed too good to treat will have early neurological deterioration, in contrast to other studies. Decisions about whether to treat mild stroke patients depend on the outcome measure chosen, particularly when considering discharge disposition among patients who have had prior stroke. The decision to thrombolyze may ultimately rest on the nature of the presentation and deficit.
authors: Division of Stroke, Department of Neurology, Columbia University Medical Center, New York, NY, USA. jzw2@columbia.edu
authors: Joshua Z
authors: JZ
authors: Willey
authors: Joshua
authors: J
authors: Stillman
authors: Juan A
authors: JA
authors: Rivolta
authors: Julio
authors: J
authors: Vieira
authors: Margaret M
authors: MM
authors: Doyle
authors: Guillermo
authors: G
authors: Linares
authors: Adrian
authors: A
authors: Marchidann
authors: Mitchell S V
authors: MS
authors: Elkind
authors: Bernadette
authors: B
authors: Boden-Albala
authors: Randolph S
authors: RS
authors: Marshall
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D011446:Prospective Studies; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome