title: Rapidly improving stroke symptoms: a pilot, prospective study.
abstract: BACKGROUND
  Rapidly improving stroke symptoms (RISSs) are a controversial exclusion for intravenous recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke (AIS). We estimated the frequency of 4 prespecified RISS definitions and explored their relationship to clinical outcome.
  
  
  METHODS
  Pilot, prospective study of AIS patients admitted within 4.5 hours of symptom onset. Serial assessments using National Institute of Health Stroke Scale (NIHSS) were performed every 20 ± 5 minutes until a rt-PA treatment decision was made, independent of the study. Improvement was calculated as the difference between baseline NIHSS and treatment decision NIHSS. RISS was defined as a 4-point or greater improvement, 25% or greater, 50% or greater, and according to the previously reported TREAT (The Re-examining Acute Eligibility for Thrombolysis) criteria. Unfavorable outcome was defined as modified Rankin Scale score more than 1 at 90 days after stroke. Logistic regression determined if RISS definition(s) related to the outcome.
  
  
  RESULTS
  Fifty patients with AIS were enrolled: mean age 65 years; median baseline NIHSS score 5 (interquartile range, 2-11). RISS frequencies were 10%-22% based on definition. Median treatment decision NIHSS score is 5 (interquartile range, 2-9). Twenty-three (46%) patients received rt-PA. None of the 3 non-TREAT RISS definitions was independently associated with the outcome. Five of fifty (10%) were RISS according to the TREAT criteria, all 5 had good outcome without rt-PA.
  
  
  CONCLUSIONS
  A Serial NIHSS assessment before treatment decision is feasible and may help determine the frequency and magnitude of RISS. This is the first prospective estimate of RISS frequency and outcome according to various prespecified definitions. The TREAT RISS frequency as a more restrictive definition may better predict good outcome of RISS in future, larger studies.
authors: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York.
authors: Clotilde
authors: C
authors: Balucani
authors: Department of Physiology and Pharmacology, SUNY Downstate Medical Center, Brooklyn, New York.
authors: Riccardo
authors: R
authors: Bianchi
authors: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York; Department of Physiology and Pharmacology, SUNY Downstate Medical Center, Brooklyn, New York.
authors: Charles
authors: C
authors: Ramkishun
authors: Scientific Computing Center, SUNY Downstate Medical Center, Brooklyn, New York.
authors: Jeremy
authors: J
authors: Weedon
authors: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York.
authors: Susan
authors: S
authors: Law
authors: Scientific Computing Center, SUNY Downstate Medical Center, Brooklyn, New York.
authors: Michael
authors: M
authors: Szarek
authors: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York.
authors: Diana
authors: D
authors: Rojas-Soto
authors: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York.
authors: Sara
authors: S
authors: Tariq
authors: Department of Neurology and Stroke Center, SUNY Downstate Medical Center, Brooklyn, New York; Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York; Department of Neurology, Kings County Hospital Center, Brooklyn, New York. Electronic address: steven.levine@downstate.edu.
authors: Steven R
authors: SR
authors: Levine
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000175:diagnosis* / Q000188:drug therapy; D000066491:Clinical Decision-Making; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / 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
keywords: Acute stroke; National Institutes of Health Stroke Scale; minor stroke; rapidly improving stroke symptoms; thrombolysis; tissue plasminogen activator