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Medical treatment of acute stroke with tissue plasminogen activator (tPA) was recently approved in the United States, and neuroprotective agents are being developed. Should all patients with stroke, regardless of severity, receive such treatment? In the Copenhagen Stroke Study we studied the prognosis of stroke in 1,351 unselected patients from a well-defined catchment area treated in a community-based stroke unit from the time of acute admission to death or the end of rehabilitation. Outcome measures were mortality, discharge rates to the patients' own home or to a nursing home, length of hospital stay, and neurological and functional outcomes. Prognosis was stratified according to initial stroke severity measured by the Scandinavian Neurological Stroke Scale (SSS) on admission. We estimated the effect of medical treatment on prognosis and health care utilization by assuming a medically induced decrease in initial stroke severity by 5 and 10 points in the initial SSS score. This mild and moderate decrease in initial stroke severity corresponded to an overall improvement in outcome and an overall cost reduction through shorter hospital stays. This was also true in patients with both mild and moderate stroke. However, in patients with severe stroke, survival increases expenses because of an increased discharge rate to a nursing home and an increase in the cost of acute care and rehabilitation. Future medical stroke trials should therefore focus on the effect and cost of treatment, especially in patients with severe stroke, and search for factors predictive of good clinical outcome in this group.
Jørgensen et al. (Sat,) studied this question.