Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis

Georgios Tsivgoulis; Ramin Zand; Aristeidis H Katsanos; Nitin Goyal; Ken Uchino; Jason Chang; Efthimios Dardiotis; Jukka Putaala; Anne W Alexandrov; Marc D Malkoff; Andrei V Alexandrov

doi:10.1161/STROKEAHA.115.009012

Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis

Stroke. 2015 May;46(5):1281-7. doi: 10.1161/STROKEAHA.115.009012. Epub 2015 Mar 19.

Affiliation

¹ From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.).

PMID: 25791717
DOI: 10.1161/STROKEAHA.115.009012

Abstract

Background and purpose: Shortening door-to-needle time may lead to inadvertent intravenous thrombolysis (IVT) administration in stroke mimics (SMs). We sought to determine the safety of IVT in SMs using prospective, single-center data and by conducting a comprehensive meta-analysis of reported case-series.

Methods: We prospectively analyzed consecutive IVT-treated patients during a 5-year period at a tertiary care stroke center. A systematic review and meta-analysis of case-series reporting safety of IVT in SMs and confirmed acute ischemic stroke were conducted. Symptomatic intracerebral hemorrhage was defined as imaging evidence of ICH with an National Institutes of Health Stroke scale increase of ≥4 points. Favorable functional outcome at hospital discharge was defined as a modified Rankin Scale score of 0 to 1.

Results: Of 516 consecutive IVT patients at our tertiary care center (50% men; mean age, 60±14 years; median National Institutes of Health Stroke scale, 11; range, 3-22), SMs comprised 75 cases. Symptomatic intracerebral hemorrhage occurred in 1 patient, whereas we documented no cases of orolingual edema or major extracranial hemorrhagic complications. In meta-analysis of 9 studies (8942 IVT-treated patients), the pooled rates of symptomatic intracerebral hemorrhage and orolingual edema among 392 patients with SM treated with IVT were 0.5% (95% confidence interval, 0%-2%) and 0.3% (95% confidence interval, 0%-2%), respectively. Patients with SM were found to have a significantly lower risk for symptomatic intracerebral hemorrhage compared with patients with acute ischemic stroke (risk ratio=0.33; 95% confidence interval, 0.14-0.77; P=0.010), with no evidence of heterogeneity or publication bias. Favorable functional outcome was almost 3-fold higher in patients with SM in comparison with patients with acute ischemic stroke (risk ratio=2.78; 95% confidence interval, 2.07-3.73; P<0.00001).

Conclusions: Our prospective, single-center experience coupled with the findings of the comprehensive meta-analysis underscores the safety of IVT in SM.

Keywords: intracranial hemorrhages; misdiagnosis; safety; stroke; tissue-type plasminogen activator.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Systematic Review

MeSH terms

Aged
Aged, 80 and over
Brain Ischemia / complications
Brain Ischemia / therapy
Female
Fibrinolytic Agents / administration & dosage
Fibrinolytic Agents / therapeutic use
Humans
Injections, Intravenous
Intracranial Hemorrhages / complications
Intracranial Hemorrhages / therapy
Male
Middle Aged
Prospective Studies
Stroke / drug therapy*
Tertiary Care Centers
Thrombolytic Therapy / adverse effects*
Thrombolytic Therapy / methods*
Time-to-Treatment

Substances

Fibrinolytic Agents