Thrombolytic therapy for stroke in patients with preexisting cognitive impairment

Objective: We aimed to evaluate the influence of prestroke cognitive impairment (PSCI) on outcomes in stroke patients treated with IV recombinant tissue plasminogen activator (rtPA).

Methods: OPHELIE-COG was a prospective observational multicenter study conducted in French and Japanese patients treated with IV rtPA for cerebral ischemia. The preexisting cognitive status was evaluated by the short version of the Informant Questionnaire on Cognitive Decline in the Elderly. PSCI was defined as a mean score >3. The primary endpoint was a favorable outcome (modified Rankin Scale [mRS] score 0–1) after 3 months. Secondary endpoints were symptomatic intracerebral hemorrhage (sICH), mRS scores 0–2, and mortality at 3 months. We performed a pooled analysis with Biostroke and Strokdem.

Results: Of 205 patients, 62 (30.2%) met criteria for PSCI. They were 11 years older (p < 0.001). Although they had more sICH and were less frequently independent after 3 months, they did not differ for any endpoint after adjustment for age, baseline NIH Stroke Scale score, and onset-to-needle time: sICH (odds ratio [OR] 2.78; 95% confidence interval [CI] 0.65–11.86), mRS 0–1 (OR 0.82; 95% CI 0.41–1.65), mRS 0–2 (OR 0.62; 95% CI 0.28–1.37), death (OR 0.40; 95% CI 0.08–2.03). The pooled analysis found no association of PSCI with any endpoint.

Conclusions: Ischemic stroke patients with PSCI should receive rtPA if they are eligible. This conclusion cannot be extended to severe cognitive impairment or severe strokes.

Classification of evidence: This study provides Class IV evidence that in patients with PSCI presenting with acute ischemic stroke, IV rtPA improves outcomes.