Mild Stroke and Rapidly Improving Symptoms

Despite the substantial benefit of intravenous recombinant tissue-type plasminogen activator (IV rtPA) in improving neurologic outcomes in acute ischemic stroke (AIS) patients,1,2 only about half of those patients who arrive at the hospital in time receive it.3,4 In 2009, 3.4% to 5.2% of AIS patients in the United States received thrombolytics, approximately double the rate of treatment in 2005.5 Rapid recognition and transport and quick treatment in the Emergency Department are clear goals for further improving treatment rates.5There have been more controversial barriers to the use of IV rtPA treatment. Prior studies6–10 have estimated that 29% to 43% of AIS patients arriving within 3 hours of symptom onset are not treated with IV rtPA because of “mild stroke” or “rapidly improving stroke symptoms” (RISS). In this issue of Stroke , Smith et al11 have reported important results from the American Heart Association Get With The Guidelines (GWTG) nationwide program11,12 involving 1290 participating hospitals, the largest data set to date analyzing outcomes of mild stroke and RISS. During the last 6 years, among 93 517 AIS patients arriving within 2 hours of symptom onset, almost one third (29 200 patients) were excluded from IV rtPA treatment solely because they presented with mild stroke or RISS. This would not be of concern if the outcomes of AIS patients with mild stroke or RISS were invariably benign. However, data have suggested that this is frequently not true.9,13 Their outcome is indeed unpredictable, as confirmed by Smith et al.11 In the GWTG population, ≈28% went to inpatient rehabilitation or skilled-nursing facilities and 1% died; almost 30% were not fully functionally independent at hospital discharge. These outcomes were worse than those of patients diagnosed with …