Outcomes of Patients with Acute Ischemic Stroke Who Declined Intravenous Thrombolytic Therapy in the Emergency Department: A Retrospective Cohort Study

Background: This study retrospectively examined patients who presented to the emergency department within 4.5 hours of symptom onset and were diagnosed with ischemic stroke. We aimed to compare the outcomes of patients who met the criteria for intravenous thrombolytic therapy but refused treatment with those who received it. Methods: Intravenous recombinant tissue plasminogen activator (IV rtPA) was offered to all eligible patients. For those unable to provide consent, information was shared with first-degree relatives. Patients were assigned to the treatment group (TG) if they accepted therapy and to the refusal group (RG) if they declined. Results: A total of 274 patients were included in the study. Comorbidities like diabetes, coronary artery disease, and hyperlipidemia were more prevalent in RG. TG patients presented with more severe strokes (higher National Institutes of Health Stroke Scale Score [NIHSS], lower Glasgow Coma Scale [GCS]). RG had better 90-day outcomes (Modified Rankin Score [mRS] 0–1) and greater functional independence (mRS 0–2). Poor outcomes (mRS 4–6) and complications, particularly intracranial hemorrhage, were more common in TG. No link was found between thrombolysis timing and complication rates. In patients under 80, RG outcomes were better; in those ≥80, outcomes were similar between groups. Conclusion: This study indicates that patients who refuse intravenous thrombolytic therapy, especially those under the age of 80, tend to have milder strokes and better short-term functional outcomes. Conversely, patients who receive treatment often face more complications and worse outcomes, likely because their initial strokes are more severe. We recommend that thrombolytic treatment decisions be individualized based on stroke severity, age, and patient preferences. Additionally, efforts should be made to enhance communication strategies during emergencies to facilitate informed decisionmaking.