title: A very early neurological improvement after intravenous thrombolysis for acute cerebral ischaemia does not necessarily predict a favourable outcome.
abstract: In patients treated by intravenous (i.v.) thrombolytic therapy for cerebral ischaemia, a very early neurological improvement (VENI) [National Institutes of Health Stroke Scale score (NIHSSS) 0, or early improvement ≥5 points], predicts a favourable outcome. VENI patients are usually excluded from trials testing complementary strategies, but a few of them have bad outcomes. To determine why VENI patients may have bad outcomes, we analysed the reasons for bad outcomes [modified Rankin Scale (mRS) score 2-6 at 3 months] in consecutive VENI patients. Of 365 consecutive patients with a pre-stroke mRS 0-1 (185 men, median age 69 years, median NIHSSS 12, median onset-to-needle time 147 min), 71 (19.5 %) had VENI. They were more likely to have had recent transient ischaemic attacks (OR 3.64, 95 % CI 1.08-12.27), higher baseline NIHSSS (median 14 vs. 11, p = 0.003) and shorter onset-to-needle times (median 135 min vs. 151, p = 0.01), and they were less likely to develop pneumonia (OR 0.27, 95 % CI 0.09-0.76) or malignant infarction (p = 0.045). In the 21 VENI patients (29.6 %) with a mRS 2-6 at 3-months, bad outcomes were due to the residual deficit in 14, secondary worsening of ischaemia in 4, intracranial haemorrhage in 2, and death from cancer in 1. One-third of VENI patients have bad outcomes, due to the residual neurological deficit in most of them. This finding suggests that VENI patients who still have a significant neurological deficit 1 h after thrombolysis should not be excluded from trials testing complementary strategies.
authors.affiliation: Department of Neurology, Univ Lille Nord de France, CHU Lille, EA 1046, 59000, Lille, France.
authors.forename: Marie
authors.initials: M
authors.lastname: Bodenant
authors.forename: Stéphanie
authors.initials: S
authors.lastname: Debette
authors.forename: Charlotte
authors.initials: C
authors.lastname: Cordonnier
authors.forename: Frédéric
authors.initials: F
authors.lastname: Dumont
authors.forename: Hilde
authors.initials: H
authors.lastname: Hénon
authors.forename: Régis
authors.initials: R
authors.lastname: Bordet
authors.forename: Didier
authors.initials: D
authors.lastname: Leys
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000188:drug therapy*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator