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October 06, 2020Research

Thrombolytic refusal over telestroke

Alicia Zha, Adriana Rosero, Rene Malazarte, Shima Bozorgui, Christy Ankrom, Liang Zhu, Michele Joseph, Alyssa Trevino, Tiffany D. Cossey, Sean Savitz, Tzu Ching Wu, Amanda Jagolino-Cole
First published October 6, 2020, DOI: https://doi.org/10.1212/CPJ.0000000000000975
Alicia Zha
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Adriana Rosero
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Rene Malazarte
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Shima Bozorgui
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Christy Ankrom
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Liang Zhu
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Michele Joseph
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Alyssa Trevino
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Tiffany D. Cossey
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Sean Savitz
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Tzu Ching Wu
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Amanda Jagolino-Cole
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth®) McGovern Medical School, Houston, TX.
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Citation
Thrombolytic refusal over telestroke
Alicia Zha, Adriana Rosero, Rene Malazarte, Shima Bozorgui, Christy Ankrom, Liang Zhu, Michele Joseph, Alyssa Trevino, Tiffany D. Cossey, Sean Savitz, Tzu Ching Wu, Amanda Jagolino-Cole
Neurol Clin Pract Oct 2020, 10.1212/CPJ.0000000000000975; DOI: 10.1212/CPJ.0000000000000975

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Abstract

Introduction Tissue plasminogen activator (tPA) refusal is 4%–6% for acute ischemic stroke (AIS) in the emergency room. Telestroke (TS) has increased the use of tPA for AIS, but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons.

Methods Patients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA.

Results Among the 1242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic black patients and patients with prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and was associated with a final diagnosis of stroke mimic (odds ratio [0.23]; 95% confidence interval [CI] 0.15–0.36). Good outcome (90 days modified Rankin Scale 0–2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42–1.54). The most common reasons for refusal were rapidly improving and mild/non-disabling symptoms and concern for potential side effects.

Conclusion tPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared to those who refused. Sex and racial differences associated with an increase tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.

Footnotes

  • ↵* These authors have contributed equally to this manuscript.

  • Received April 17, 2020.
  • Accepted August 26, 2020.
  • © 2020 American Academy of Neurology

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