Abstract WP64: Mild Strokes: To Treat or Not To Treat

Background: Over half of the ischemic strokes in the US are "mild" by NIHSS scores at presentation.The most common reason for witholding tPA in patients who arrive in time is that the stroke is "too mild."Based on mounting evidence that mild strokes may cause significant disability, the stroke team at Saint Luke’s Neuroscience Institute (SLNI) began to consider mild strokes (NIHSS 0-5) eligible for treatment with intravenous tissue plasminogen activator (IVtPA) in 2009.This analysis evaluated whether more aggressive treatment of mild strokes with IVtPA resulted in better overall outcomes measured by a greater percentage of patients being discharged home with fewer discharges to skilled nursing (SNF) and lower mortality. Methods: We retrospectively reviewed strokes in the SLNI database with presenting NIHSS scores of 0-5 in 2007/2008, and in 2010/2011 by treatment status and discharge disposition. Results: In 2007/2008, there were 342 mild strokes; 11(3.2 %)received tPA.In 2010,2011 there were 432 mild strokes; 62(15.7%)received tPA (p=0.001).Overall discharge to home: 218/342(63.7%) in 07/08 and 310/432(71.8%) in 10/11 (p=0.017). Discharge to SNF: 45/342(13.2%)in 07/08; 42/432(9.7%) in 10/11 p=0.133. In cases treated with IVtPA in both cohorts, discharge to SNF=5/79(6.3%); no IVtPA=82/695(11.8%)p=0.108. Mortality: 9/342 (2.6%) in 07/08 and 3/342(0.7%) in 10/11 (p=0.030).Of the 12 total mortalities, 2 were treated with IVtPA.There were no statistically significant differences in the percentage of discharges to rehabilitation in the two cohorts. Conclusions: It is safe to administer IVtPA to patients with mild strokes.There is a trend toward more aggressive treatment of mild strokes with tPA being associated with a higher likelihood of being discharged to home, fewer discharges to SNF, and lower mortality in the group as a whole.A randomized prospective trial would be useful to further direct decision making in this group of patients.