Poor prognosis of acute stroke patients denied thrombolysis due to early CT findings

Objectives. Whether acute stroke patients with major early infarct signs on computed tomography (CT) should be treated with intravenous (IV) thrombolysis remains controversial. The authors sought to define the outcomes in 5 consecutive patients who were not treated with IV thrombolysis, according to established guidelines. Methods. The authors retrospectively analyzed the outcomes of a consecutive series of 5 patients evaluated by an acute stroke team at a university medical center and who were denied IV tissue plasminogen activator due to early CT changes. Results. Five patients with a median National Institutes of Health Stroke Scale score of 22 (range 20-28) were evaluated. Despite aggressive care (e.g., hemicraniectomy), 2 patients died owing to herniation, 1 patient died of cardiac causes, and neither of the 2 surviving patients achieved a 3-month Rankin score below 4 (moderately severe disability). Conclusions. Given the poor prognosis of patients with hemispheric stroke and early CT changes, alternative treatment modalities such as intra-arterial thrombolysis, early hemicraniectomy, and neuroprotective therapy should be vigorously pursued.