Background: Intravenous (IV) recombinant tissular plasminogen activator (rt-PA) is the only approved pharmacological treatment for acute ischemic stroke. We aimed to analyze potential causes of the variable effect on early course and late outcome.
Methods and results: 136 patients (42% women, 58% men) treated with IV rt-PA within 3 hours of stroke onset in an acute stroke unit over a three-year period, were included. Early clinical profiles of evolution at 48 hours were divided into clinical improvement (CI) (decrease >4 points in the National Institute of Health Stroke Scale (NIHSS)); clinical worsening (CW) (increase >4 points NIHSS); clinical worsening after initial improvement (CWFI) (variations of >4 points in the NIHSS). Patients with clinical stability (no NIHSS modification or < 4 points) were excluded. Our patients showed in 66.9% CI, 13.2% CW 8.1 % CWFI and 11.8% remained stable. Female sex, no hyperlipemia and peripheral arterial disease were associated with CW. Male sex and smoking were associated with CI. Absence of arterial occlusion on admission (28.4%) and arterial recanalization at 24 hours were associated with CI. Main causes of clinical deterioration included symptomatic intracranial haemorrhage (sICH), persistent occlusion and cerebral edema. 23.5% developed ICH, 6.6% of which had sICH. At 3 months, 15.5% had died. Mortality was increased in CW, mainly related to sICH and cerebral edema. Outcome of CWFI was intermediate between CW and CI.
Conclusions: Early clinical profiles of evolution in thrombolyzed patients vary considerably. Even with CI it is critical to maintain vessel permeability to avoid subsequent CW.