DETERMINANTS OF POOR FUNCTIONAL OUTCOMES; AFTER INTRAVENOUS THROMBOLYSIS IN ACUTE ISCHEMIC STROKE: INSIGHTS FROM A TERTIARY CARE HOSPITAL IN PAKISTAN

Abstract

Purpose
Intravenous thrombolysis (IVT) is the gold standard treatment for eligible patients with acute ischemic stroke (AIS), significantly improving functional outcomes when administered within the recommended therapeutic window. However, despite timely intervention, a considerable proportion of patients experience poor recovery. This study aims to identify clinical, radiological, and demographic determinants of poor functional outcomes in AIS patients who received IVT at a tertiary care hospital in Pakistan. By recognizing these predictors, we seek to enhance risk stratification, optimize post-stroke care, and improve patient management strategies in resource-limited settings.

Materials and Methods

This retrospective observational study was conducted at Ayub Teaching Hospital, Abbottabad, Pakistan, including all adult patients (≥18 years) diagnosed with AIS who received IVT within 4.5 hours of symptom onset between July 2023 and March 2024. Data were collected retrospectively from medical records, including baseline demographics, stroke severity (NIHSS score), comorbidities, neuroimaging findings, in-hospital complications, and discharge status. Functional outcomes were assessed using the modified Rankin Scale (mRS) at 90 days, classifying patients into good (mRS 0–2) and poor (mRS 3–6) outcome groups. Univariable and multivariable logistic regression analyses were performed to determine independent predictors of poor functional outcomes. A predictive model was developed based on significant variables, and its accuracy was validated using receiver operating characteristic (ROC) curve analysis. The findings from this study will provide valuable insights into post-thrombolysis outcomes in the local population, aiding in the development of targeted interventions for better stroke recovery.

Results

A total of 152 patients who received intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) at Ayub Teaching Hospital, Abbottabad, were included. The mean age was 62.3 ± 11.5 years, with a male predominance (58.6%). At the 90-day follow-up, 98 patients (64.5%) had good functional outcomes (modified Rankin Scale [mRS] 0–2), while 54 (35.5%) had poor outcomes (mRS 3–6), including 12 (7.9%) mortalities. Multivariable logistic regression identified older age (AOR 1.05; 95% CI 1.01–1.09; P = 0.04), hypertension (AOR 3.21; 95% CI 1.45–7.12; P = 0.005), higher admission NIHSS (AOR 1.12; 95% CI 1.04–1.20; P = 0.002), symptom-to-needle time > 180 minutes (AOR 2.89; 95% CI 1.32–6.31; P = 0.008), and lower ASPECTS (AOR 0.61; 95% CI 0.42–0.89; P = 0.01) as independent predictors of poor functional outcomes. The predictive model demonstrated strong accuracy, with an area under the receiver operating characteristic curve (AuROC) of 0.826 (95% CI 0.755–0.897). Subgroup analysis showed significantly worse outcomes in patients aged ≥ 65 years (OR 2.74, P = 0.006), NIHSS ≥ 15 (OR 4.2, P < 0.001), and symptom-to-needle time > 180 minutes. These findings highlight the importance of early intervention and risk stratification in AIS patients receiving IVT.

Conclusion

This study highlights that older age, hypertension, higher baseline NIHSS, prolonged symptom-to-needle time, and lower ASPECTS on initial brain imaging are significant predictors of poor functional outcomes following IVT in acute ischemic stroke patients. These findings emphasize the need for early intervention, optimized blood pressure control, and rapid thrombolysis administration to improve post-stroke recovery. Future prospective studies are warranted to validate these predictors and refine patient selection criteria for IVT in resource-limited settings.