The American Academy of Neurology and the American Heart Association have advocated the use of tissue-type plasminogen activator (tPA) for treatment of patients with acute ischemic stroke. However, few of the patients who are eligible for this treatment receive it, possibly because of concern over the risk of symptomatic intracranial hemorrhage. Albers and colleagues studied the outcomes associated with the use of tPA in clinical practice.
A total of 389 patients were included in the study. All of the patients had acute ischemic stroke and received treatment with tPA. Information was gathered about the elapsed time between the onset of stroke symptoms and the administration of tPA. All of the patients underwent computed tomographic (CT) scanning of the head. Clinical course was followed, and an urgent CT was performed if patients had neurologic deterioration. Patients were followed for 30 days after tPA treatment to determine the occurrence of serious adverse effects and functional outcome.
The median time from onset of symptoms until tPA administration was two hours, 44 minutes, and the median time from presentation to the hospital and administration of tPA was one hour, 36 minutes. Patients who arrived at the hospital the soonest after onset of symptoms had longer delays before tPA administration. Thirteen patients (3.3 percent) had symptomatic intracranial hemorrhage occurring within three days of tPA administration, and seven of these patients died. Asymptomatic intracranial hemorrhage within three days of treatment occurred in 28 patients (8.2 percent), and major systemic bleeding events occurred in six patients (1.5 percent). At the 30-day follow-up, 51 patients had died. A favorable outcome was seen in 35 percent of treated patients, and 43 percent of patients were functionally independent. Favorable outcomes were more likely in patients whose strokes were less severe, who had no specific abnormalities on CT scan, who were younger than 85 years and who had lower initial mean arterial pressure.
The authors conclude that, in clinical practice, the risk of symptomatic intracranial hemorrhage at three days was lower than had been found in the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial (3.3 versus 6.4 percent). It seems that it is possible to achieve favorable outcomes and low rates of symptomatic intracranial hemorrhage by using tPA in the treatment of patients with acute ischemic stroke.
In a related editorial, Mohr lauds the approaches that have been made in the treatment of acute ischemic stroke, decries the previously held nihilistic attitude toward the success of treatment and advises that optimal benefit may be derived if physicians follow guidelines for patient selection and treatment, and individualized plans of care.