Thrombolysis After Stroke: issues and controversies  added 09/30/00

subtitle: A recent review supports the use of tPA against ischemic attacks, but only if one has a through understanding of its indications and a well-trained support team      in  Emergency Medicine June 2000

"Of those patients fortunate enough to survive as long as seven years after a stroke, 
20% require assistance walking, 
31% need help caring for themselves, and 
71% have problems at work,     according to the Framingham Heart Study"

The initial tPA NINDS 1995 study which included 600 subjects found that patients given tPA within three hours of stroke onset has substantially better results at three months in terms of resolved symptoms, better overall function, and lower Stroke Scale (NIHSS). 

"The latest good news, published in 1999, is that every one year after therapy, patients given tPA continue to enjoy superior function and have a better change of a good outcome (New England Journal of Medicine Vol 340, pg 1781, 1999)"

A Dr. Marian P. LaMonte at Univ. of Maryland has reviewed all of the tPA studies which have included at least 100 patients with ischemic stroke confirmed by computed tomography (CT).  This included the following

• MAST-E  Multicenter Acute Stroke Trial-Europe
• MAST-I Multicenter Acute Stroke Trial - Italy
• ASK  Australian Streptokinase
• NINDS  National Institute of Neurological Disorders and Stroke
• ECASS  European Cooperative Acute Stroke Study
• ECASSS II European and Australian Cooperative Acute Stroke Study II
• ATLANTIS Alteplase Thrombolysis for Acute Noninterventional Treatment in Ischemic Stroke
• STAT  Stroke Treatment with Ancrod Trial (published in JAMA May 2000 vol 283 pg 2395)
  

"All of the evidence that giving the drug outside of the golden window not only erases the benefits thrombolysis offers but substantially increase the hazards associated with it."

" The single most important factor excluding patients from thrombolytic therapy was presentation after the three-hour golden window had passed."  Only 4% of the patients in the NINDS study meet the criteria for tPA therapy.

 Example:  tPA can not given if a stroke did not wake up a sleeping person.