Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.
Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Ann Neurol. 2019 Nov;86(5):770-779. doi: 10.1002/ana.25582. Epub 2019 Sep 9.
Seizure at onset (SaO) has been considered a relative contraindication for intravenous thrombolysis (IVT) in patients with acute ischemic stroke, although this appraisal is not evidence based. Here, we investigated the prognostic significance of SaO in patients treated with IVT for suspected ischemic stroke.
In this multicenter, IVT-registry-based study we assessed the association between SaO and symptomatic intracranial hemorrhage (sICH, European Cooperative Acute Stroke Study II definition), 3-month mortality, and 3-month functional outcome on the modified Rankin Scale (mRS) using unadjusted and adjusted logistic regression, coarsened exact matching, and inverse probability weighted analyses.
Among 10,074 IVT-treated patients, 146 (1.5%) had SaO. SaO patients had significantly higher National Institutes of Health Stroke Scale score and glucose on admission, and more often female sex, prior stroke, and prior functional dependence than non-SaO patients. In unadjusted analysis, they had generally less favorable outcomes. After controlling for confounders in adjusted, matched, and weighted analyses, all associations between SaO and any of the outcomes disappeared, including sICH (odds ratio [OR] = 1.53 [95% confidence interval (CI) = 0.74-3.14], OR = 0.52 [95% CI = 0.13-2.16], OR = 0.68 [95% CI = 0.15-3.03], OR = 0.95 [95% CI = 0.39-2.32]), mortality (OR = 1.49 [95% CI = 1.00-2.24], OR = 0.98 [95% CI = 0.5-1.92], OR = 1.13 [95% CI = 0.55-2.33], OR = 1.17 [95% CI = 0.73-1.88]), and functional outcome (mRS ≥ 3/ordinal mRS: OR = 1.33 [95% CI = 0.96-1.84]/1.35 [95% CI = 1.01-1.81], OR = 0.78 [95% CI = 0.45-1.32]/0.78 [95% CI = 0.52-1.16], OR = 0.75 [95% CI = 0.43-1.32]/0.45 [95% CI = 0.10-2.06], OR = 0.87 [95% CI = 0.57-1.34]/1.00 [95% CI = 0.66-1.52]). These results were consistent regardless of whether patients had an eventual diagnosis of ischemic stroke (89/146) or stroke mimic (57/146 SaO patients).
SaO was not an independent predictor of poor prognosis. Withholding IVT from patients with assumed ischemic stroke presenting with SaO seems unjustified. ANN NEUROL 2019;86:770-779.
尽管没有证据支持，但发作性癫痫（SaO）被认为是急性缺血性脑卒中患者静脉溶栓（IVT）的相对禁忌证。在此，我们研究了 SaO 对接受 IVT 治疗的疑似缺血性脑卒中患者的预后意义。
在这项多中心、基于 IVT 登记的研究中，我们使用未调整和调整后的逻辑回归、粗糙精确匹配和逆概率加权分析，评估 SaO 与症状性颅内出血（sICH，欧洲合作急性卒中研究 II 定义）、3 个月死亡率和改良 Rankin 量表（mRS）上的 3 个月功能结局之间的关联。
在 10074 例接受 IVT 治疗的患者中，有 146 例（1.5%）出现 SaO。SaO 患者入院时 NIHSS 评分和血糖明显较高，且更常为女性、既往卒中史和既往功能依赖，而非 SaO 患者。在未调整的分析中，他们的预后普遍较差。在调整后的匹配和加权分析中控制混杂因素后，SaO 与任何结局之间的所有关联均消失，包括 sICH（比值比 [OR] = 1.53 [95%置信区间（CI）= 0.74-3.14]，OR = 0.52 [95% CI = 0.13-2.16]，OR = 0.68 [95% CI = 0.15-3.03]，OR = 0.95 [95% CI = 0.39-2.32]）、死亡率（OR = 1.49 [95% CI = 1.00-2.24]，OR = 0.98 [95% CI = 0.5-1.92]，OR = 1.13 [95% CI = 0.55-2.33]，OR = 1.17 [95% CI = 0.73-1.88]）和功能结局（mRS≥3/ordinal mRS：OR = 1.33 [95% CI = 0.96-1.84]/1.35 [95% CI = 1.01-1.81]，OR = 0.78 [95% CI = 0.45-1.32]/0.78 [95% CI = 0.52-1.16]，OR = 0.75 [95% CI = 0.43-1.32]/0.45 [95% CI = 0.10-2.06]，OR = 0.87 [95% CI = 0.57-1.34]/1.00 [95% CI = 0.66-1.52]）。无论患者最终诊断为缺血性卒中（89/146）还是卒中模拟（57/146 SaO 患者），这些结果都是一致的。
SaO 不是不良预后的独立预测因素。对疑似缺血性脑卒中发作患者伴发 SaO 而不进行 IVT 治疗似乎是不合理的。
