Abstract Body: Introduction
The use of IV thrombolysis (IVT) in acute ischemic stroke patients presenting with an NIHSS of ≤ 5 has failed to demonstrate benefit, particularly when the symptoms are considered non-disabling. This critical disability distinction, however, is often made subjectively by the treating physician at the bedside. This may complicate and delay decision-making or lead to unnecessary dosing of thrombolytic agents, especially when symptoms such as paresis, visual field loss (VFL), or aphasia are present, despite having no impact on clinical outcome.
Hypothesis
The implementation of an objective scoring system, as used in the ARAMIS Trial, utilizing non-disabling NIHSS individual sub-score cut-offs (NdSSC) [≤ 1 for single limb weakness, aphasia, VFL and neglect] will reduce excess utilization of IVT in this patient population.
Methods
This single-center, retrospective cohort study included IVT candidates with an NIHSS ≤ 5, either in-person or via tele-stroke, from 2019 to 2023. Baseline characteristics were compared between those treated and not treated based solely on an exclusion of "mild non-disabling symptoms." A logistic regression analysis was performed to identify any variables influencing this treatment decision. Potential excess utilization of IVT was determined by applying objective NdSSC criteria to patients who received IVT, and the Kappa statistic was calculated to evaluate agreement.
Results
A total of 2,565 patients were included in the analysis, with 47.2% (n = 1210) receiving IVT. 72.4% (876/1210) of these patients who received IVT would not have been recommended for therapy under the NdSSC Criteria. In the overall population, a net total 32.8% more patients received lytic therapy than would have been recommended under the NdSSC Criteria. (Kappa = 0.26 [95% CI 0.23 – 0.29]) (Table 1). Adjusted analyses did not show any significant effect on treatment decision for age, race, time of day, tele-stroke vs. in-house, paresis, aphasia, visual loss, and neglect (Table 2).
Conclusion
In acute ischemic stroke patients with an NIHSS ≤ 5, using standard of care, subjective decision-making, compared to objective criteria, led to a potential excess use of IVT in over 30% of cases.