Right Hemisphere Ischemia is more likely to Cause Falsely "Mild" Symptoms and Poor Outcomes without Thrombolysis

Rapidly improving or mild symptoms is the most common reason that acute stroke patients arriving within the approved time window are not treated with intravenous tissue-type plasminogen activator (IV tPA). We reviewed outcomes at discharge for patients excluded from IV tPA because of rapidly improving or mild symptoms, with the aim of being better able to identify patients who may benefit from thrombolysis.

All patients between April 2006 and June 2010 from our center who did not receive IV tPA with "rapidly improving or mild symptoms" as the reason for exclusion were identified. Poor outcome was defined as hospital discharge to location other than home or inability to ambulate independently at discharge.

There were 66 patients excluded from tPA treatment because of rapidly improving or mild symptoms. Eleven patients (16.7%) had poor outcomes. In 6 patients (9%), poor outcome was due to neurologic deficit. All 6 patients with neurologic deficits had right hemisphere strokes, and one also had cerebellar infarcts.

Patients presenting with rapidly improving or mild symptoms do not universally have good outcomes. This may be particularly true in the case of right hemispheric ischemia where deficits are not fully reflected by NIHSS score. If a patient with a low NIHSS score is otherwise a candidate for tPA, a more detailed exam is warranted to better identify potentially disabling deficits that might benefit from thrombolysis.