Chirantan Banerjee, MD
Thrombolysis revolutionized stroke care in the 1990s. We continue to advance stroke care, most recently with the advent of newer generation and more effective intra-arterial thrombolytic techniques. In all of the randomized trials and registries, the outcome is mostly assessed at 90 days. There are a few studies that have followed patients up to a year. Long term outcome data is very limited. Schmitz et al in 2014 reported that among Danish patients, treatment with intravenous tPA was associated with a lower risk of long-term mortality (adjusted hazard ratio, 0.66) at 1.4 years. In a Swiss cohort, at 3 years after IVT, approximately 1 of 3 stroke patients had an excellent outcome, and 1 of 3 had died.
In the current study, Machado et al report on functional outcome at 5 years in a prospective registry of patients who underwent IV thrombolysis at their stroke unit in Braga, Portugal between 2007-2010. Five year outcome was determined using telephonic interviews with patients or family surrogates. They report that one third of patients had mRS 0-1, but nearly half had died in the interim. They also found that NIHSS 24 hours after thrombolysis, rather than admission NIHSS was a predictor of excellent five year outcome. This is heartening to see, as it emphasizes the importance of vessel recanalization even 5 years down the line, regardless of initial clinical severity. With regards to mortality, because of limited data on post thrombolysis mortality at 5 years, it is difficult to contrast this data against others. But it is a little upsetting to note that as compared to natural history data from the pre-thrombolytic era, there isn’t a notable improvement, despite improvement in overall medical care since. This highlights the need to focus on developing more concrete protocols that would prevent medical complications after stroke, like pneumonia, deep venous thrombosis etc. Stroke should be viewed not just an acute neurologic insult, but a chronic medical ailment, needing continued aggressive outpatient care, even years after the initial injury.