Retrospective evaluation of mortality among stroke patients receiving thrombolytic therapy in the emergency department

Year 2025, Volume: 7 Issue: 5, 589 - 596, 15.09.2025

Emin Sancar , Abdurrahman Yılmaz , Gökçe Dağtekin , Eda Yaman , Sema Avcı

https://doi.org/10.38053/acmj.1729053

Abstract

Aims: Since strokes are an important cause of morbidity and mortality all over the world, early diagnosis and treatment are extremely important for sequela-free recovery. The best treatment option for an ischemic stroke is intravenous thrombolytic therapy with recombinant tissue plasminogen activator. In this study, we aimed to determine the factors affecting in-hospital mortality among patients who presented to the emergency department due to an ischemic stroke and received thrombolytic therapy.
Methods: This cross-sectional study reviewed the medical records of patients who presented to the emergency department with stroke symptoms between January 2018 and August 2022, were diagnosed with ischemic stroke, received thrombolytic treatment within the first 4.5 hours of symptom onset, and were subsequently hospitalized.
Results: After excluding patients who did not meet the inclusion criteria, 184 patients were included in the study. It was found that 42 (22.8%) of the patients had an exitus in the follow-up. We determined that the mortality rate was higher in patients admitted to the emergency department with emergency health services compared to outpatients (p<0.05). Mortality frequency was higher in patients who had a National Institutes of Health Stroke Scale (NIHSS) score ≥21 or were hospitalized for more than 14 days (p<0.05). In univariate analysis, age, admission route, length of hospital stay, and NIHSS score were associated with mortality. Multiple logistic regression analysis demonstrated that patients with an NIHSS score ≥21 had an 18.49-fold higher risk of death (95% CI: 6.55–52.20) compared to those with a score ≤20.
Conclusion: In our study, it was observed that the mortality rate was increased in patients who were aged 65 and over, had diabetes mellitus or atrial fibrillation comorbidities, were admitted to the hospital with emergency health services, were hospitalized for more than 14 days, and had NIHSS score of 21 and above.

Keywords

Ischemic stroke , thrombolytic therapy , mortality

Ethical Statement

This retrospective cross-sectional study was carried out in Usak Research and Training Hospital. The study protocol was accepted by Usak University Faculty of Medicine Non-Interventional Clinical Research Ethics Committee with the number/date of 65-65-19/02.02.2023. This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was waived due to the retrospective nature of the study.

Supporting Institution

The authors indicate no financial support or financial conflict of interest. The authors have indicated they have no financial relationships with any company and no external funding.

Thanks

The authors thank the doctors, nurses and all health professionals who contributed to the medical care of stroke patients.

References

• Campbell BCV, De Silva DA, Macleod MR, et al. Ischaemic stroke. Nat Rev Dis Primers. 2019;5(1):70. doi:10.1038/s41572-019-0118-8
• Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2023 update: a report from the American Heart Association. Circulation. 2023;147(8):e93-e621. doi:10.1161/CIR.0000000000001123
• Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ Res. 2017;120(3):439-448. doi:10.1161/CIRCRESAHA.116.308413
• Krishnamurthi RV, Ikeda T, Feigin VL. Global, regional and country-specific burden of ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage: a systematic analysis of the global burden of disease study 2017. Neuroepidemiology. 2020;54(2):171-179. doi:10. 1159/000506396
• Chandra A, Stone CR, Du X, et al. The cerebral circulation and cerebrovascular disease III: stroke. Brain Circ. 2017;3(2):66-77. doi:10. 4103/bc.bc_12_17
• Auer RN, Sommer CJ. Chapter 4: histopathology of brain tissue response to stroke and injury, stroke: pathophysiology, diagnosis, and management. Elsevier Inc; 2019.
• Jolugbo P, Ariëns RAS. Thrombus composition and efficacy of thrombolysis and thrombectomy in acute ıschemic stroke. Stroke. 2021; 52(3):1131-1142. doi:10.1161/STROKEAHA.120.032810
• Herpich F, Rincon F. Management of acute ischemic stroke. Crit Care Med. 2020;48(11):1654-1663. doi:10.1097/CCM.0000000000004597
• Dillon GM, Stevens S, Dusenbury WL, Massaro L, Toy F, Purdon B. Choosing the correct "-ase" in acute ischemic stroke: alteplase, tenecteplase, and reteplase. Adv Emerg Nurs J. 2019;41(3):271-278. doi: 10.1097/TME.0000000000000254
• Warach SJ, Dula AN, Milling TJ Jr. Tenecteplase thrombolysis for acute ischemic stroke. Stroke. 2020;51(11):3440-3451. doi:10.1161/STROKEAHA.120.029749
• El Husseini N, Shea KJ, Goldstein LB. Concerns for the reliability and validity of the national stroke project stroke severity scale. Cerebrovasc Dis. 2011;32(5):426-430.doi:10.1159/000331476
• TR. Ministry of Health, General Directorate of Health Services. Acute ischemic stroke diagnosis and treatment guideline. Ankara; 2020.
• Öztürk B, Özön AÖ. Ischaemic stroke and gender. Akd Med J. 2020;6(1): 59-65. doi:10.17954/amj.2019.1579
• Ji R, Schwamm LH, Pervez MA, Singhal AB. Ischemic stroke and transient ischemic attack in young adults: risk factors, diagnostic yield, neuroimaging, and thrombolysis. JAMA Neurol. 2013;70(1):51-57. doi: 10.1001/jamaneurol.2013.575
• Thrift AG, Howard G, Cadilhac DA, et al. Global stroke statistics: an update of mortality data from countries using a broad code of "cerebrovascular diseases". Int J Stroke. 2017;12(8):796-801. doi:10.1177/ 1747493017730782
• Chantkran W, Chaisakul J, Rangsin R, Mungthin M, Sakboonyarat B. Prevalence of and factors associated with stroke in hypertensive patients in Thailand from 2014 to 2018: a nationwide cross-sectional study. Sci Rep. 2021;11(1):17614. doi:10.1038/s41598-021-96878-4
• Kiyan S, Ozsarac M, Ersel M, et al. Retrospective analysis of 124 acute ischemic stroke patients who attended to the emergency department in one year period. JAEM. 2009;8:3. doi:10.4170/JAEM.2009.46330
• Dolek T, Cenikli U, Bek S, Kutlu Gunergin G. Experiences of intravenous thrombolytic therapy of Muğla in acute ischemic stroke. Med J Mugla Sitki Kocman University. 2023;10(2):115-119. doi:10.47572/muskutd. 1173741
• Demirci Sahin A, Ustu Y, Isik D, Oztas D, Karatas Eray I, Ugurlu M. Demographic characteristics of patients with cerebrovascular disease and evaluation of preventable risk factors in primary care centers. Ankara Med J. 2015;15(4):196-208. doi:10.17098/amj.79435
• Gokmen EO. Factors affecting ischemia recurrence in patients presenting to the emergency department with recurrent ischemic stroke under antiembolicor antithrombotic treatment. 2023. Access address: https://acikerisim.erbakan.edu.tr/xmlui/handle/20.500.12452/10261
• Vahdati SS, Ala A, Hejazian S, et al. Factors affecting complications and mortality of stroke patients in stroke care unit. Erciyes Med J. 2022;44(2): 138-142. doi:10.14744/etd.2021.71430
• Lau LH, Lew J, Borschmann K, Thijs V, Ekinci EI. Prevalence of diabetes and its effects on stroke outcomes: a meta-analysis and literature review. J Diabetes Investig. 2019;10(3):780-792. doi:10.1111/jdi.12932
• De Stefano F, Mayo T, Covarrubias C, Fiani B, Musch B. Effect of comorbidities on ischemic stroke mortality: an analysis of the National inpatient sample (NIS) database. Surg Neurol Int. 2021;12:268. doi:10. 25259/SNI_415_2021
• Yoshida T, Uchino S, Yokota T, Fujii T, Uezono S, Takinami M. The impact of sustained new-onset atrial fibrillation on mortality and stroke incidence in critically ill patients: a retrospective cohort study. J Crit Care. 2018;44:267-272. doi:10.1016/j.jcrc.2017.11.040
• Schrock JW, Glasenapp M, Drogell K. Elevated blood urea nitrogen/creatinine ratio is associated with poor outcome in patients with ischemic stroke. Clin Neurol Neurosurg. 2012;114(7):881-884. doi:10. 1016/j.clineuro.2012.01.031
• Watso JC, Farquhar WB. Hydration status and cardiovascular function. Nutrients. 2019;11(8):1866. doi:10.3390/nu11081866
• Crary MA, Humphrey JL, Carnaby-Mann G, Sambandam R, Miller L, Silliman S. Dysphagia, nutrition, and hydration in ischemic stroke patients at admission and discharge from acute care. Dysphagia. 2013; 28(1):69-76. doi:10.1007/s00455-012-9414-0
• Cortés-Vicente E, Guisado-Alonso D, Delgado-Mederos R, et al. Frequency, risk factors, and prognosis of dehydration in acute stroke. Front Neurol. 2019;10:305. doi:10.3389/fneur.2019.00305
• Rowat A, Graham C, Dennis M. Dehydration in hospital-admitted stroke patients: detection, frequency, and association. Stroke. 2012;43(3):857-859. doi:10.1161/STROKEAHA.111.640821
• Fonarow GC, Saver JL, Smith EE, et al. Relationship of NIHSS to 30-day mortality in medicare beneficiaries with acute ischemic stroke. J Am Heart Assoc. 2012;1(1):42-50. doi:10.1161/JAHA.111.000034
• De Havenon A, Abbasi M, Yaghi S, et al. Effect of alteplase on ischemic stroke mortality is dependent on stroke severity. Ann Neurol. 2023;93(6): 1106-1116. doi:10.1002/ana.26621
• Olum S, Muyingo A, Wilson TL, et al. Stroke mortality outcomes in Uganda. J Stroke Cerebrovasc Dis. 2021;30(5):105661. doi:10.1016/j.jstrokecerebrovasdis.2021.105661
• Ongun N. Intravenous thrombolytic therapy in acute ischemic stroke: a public hospital experience, analysis of 87 cases. Turkish J Cerebrovasc Dis. 2021;27(2):139-44. doi:10.5505/tbdhd.2021.2499
• Heuschmann PU, Kolominsky-Rabas PL, Misselwitz B, et al. Predictors of in-hospital mortality and attributable risks of death after ischemic stroke: the German Stroke Registers study group. Arch Intern Med. 2004;164(16):1761-1768. doi:10.1001/archinte.164.16.1761
• Kalra L, Yu G, Wilson K, Roots P. Medical complications during stroke rehabilitation. Stroke. 1995;26:990-994. doi:10.1161/01.str.26.6.990