The impact of lesion side on acute stroke treatment

Background — Only a small percentage of patients with acute stroke are treated with recombinant tissue plasminogen activator (rt-PA).

Objective — To investigate why patients with right-hemisphere strokes seem at high risk of not receiving rt-PA.

Methods — This study includes two phases. Phase 1: the authors compared demographic, clinical, and outcome measures between patients with right- and left-hemisphere strokes in the rt-PA Registry of Southwestern Ontario (RSWO); Phase 2: the authors tested the hypotheses generated in Phase 1 using the Registry of the Canadian Stroke Network (RCSN). A multiple logistic analysis was applied to detect independent predictors of rt-PA administration.

Results — Phase 1: of 179 rt-PA-treated patients, 39% had right-hemisphere syndrome. Patients with right-hemisphere strokes had a longer hospital stay (15 vs 9 days; p = 0.03). Phase 2: of 990 stroke patients in the RCSN, 505 (51%) had a right- and 485 (49%) a left-hemisphere syndrome. Of 110 rt-PA-treated patients, 37 (34%) had a right-hemisphere syndrome (p = 0.0001). Negative independent predictors of rt-PA administration were right-hemisphere stroke (OR, 0.55; CI: 0.31 to 0.96; p = 0.037), onset-to-emergency department time (OR, 0.99; CI 0.98 to 0.99; p = 0.04), and CNS score (OR, 0.78; CI 0.71 to 0.86; p < 0.0001). Neglect predicted rt-PA administration (OR, 2.32; CI 1.29 to 4.16; p = 0.004).

Conclusions — Patients with right-hemisphere strokes are 45% less likely to be treated with recombinant tissue plasminogen activator (rt-PA) compared to patients with left-hemisphere strokes. The presence of neglect confers a twofold increased likelihood of rt-PA administration. Prehospital delay and lack of standardized scores for the neglect syndrome may limit accessibility of patients with right-hemisphere stroke to thrombolysis.