Patient refusal of thrombolytic therapy for suspected acute ischemic stroke

ObjectiveTo determine factors associated with patients refusing IV t-PA for suspected acute ischemic stroke (AIS), and to compare the outcomes of patients who refused t-PA (RT) with those treated with t-PA. MethodsPatients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0-1), good (mRS: 0-2), and poor (mRS: 3-6). ResultsOver 75 years, 30 (42%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 063, 95% CI 050-079). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 102, 95% CI 101-103), lower NIHSS (OR 111, 95% CI 103-118), a higher proportion of stroke mimics (OR 1761, 95% CI 620-5002) and shorter hospital stay (OR 132, 95% CI 109-161). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 137, 95% CI 106-178). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 161, 95% CI 069-373). ConclusionThe incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out of six refusal patients (166%) had a stroke mimic.