Related Experiment Videos
Intravenous thrombolytic therapy for stroke: a review of recent studies and controversies
T M Osborn1, M P LaMonte, W R Gaasch
1Division of Emergency Medicine, University of Maryland Medicine Baltimore, MD 21201, USA.
Insights
Intravenous thrombolytic therapy for ischemic stroke using tissue plasminogen activator (tPA) within 3 hours shows benefit. Strict adherence to protocol is crucial for optimal outcomes in stroke treatment.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Pharmacology
Background:
- Ischemic stroke is a leading cause of disability.
- Intravenous thrombolytic therapy is a critical treatment option.
- Evaluating the efficacy and safety of different thrombolytic agents is essential.
Purpose of the Study:
- To review randomized, controlled, multicenter trials of intravenous thrombolytic therapy for ischemic stroke.
- To compare the outcomes of different thrombolytic agents and protocols.
Main Methods:
- Review of multicenter trials involving computed tomography (CT)-confirmed ischemic stroke and >100 randomized patients.
- Analysis of studies using streptokinase, tissue plasminogen activator (tPA), and ancrod.
- Discussion of factors including agent, CT interpretation, timing, dose, ancillary medications, safety, and outcomes.
Main Results:
- Streptokinase studies were halted due to increased mortality.
- The NINDS (National Institute of Neurological Disorders and Stroke) trial demonstrated improved recovery with tPA without increased mortality.
- Other tPA and ancrod trials showed mixed or inconclusive results.
Conclusions:
- Intravenous tPA at 0.9 mg/kg within a 3-hour 'golden window' is supported for ischemic stroke.
- Strict protocol adherence is vital to optimize the benefit/risk profile of tPA.
- Rapid CT access and expert collaboration are recommended for effective stroke management.
Study Objectives:
To review the randomized, controlled, multicenter trials of intravenous thrombolytic therapy for ischemic stroke.
Methods:
Studies of ischemic stroke confirmed by computed tomography (CT) and randomization of more than 100 patients are reviewed. Streptokinase studies are the MAST-I, the MAST-E, and the ASK Trial. Studies using tissue plasminogen activator (tPA) are the NINDS Stroke Study, ECASS I, ECASS II, and ATLANTIS. One study using ancrod is STAT. We discuss significant factors common to each study, including thrombolytic agent used, CT scan interpretation, time of therapy administration in relation to stroke onset, thrombolytic dose, ancillary medication administration, safety, and neurologic outcomes.
Results:
All streptokinase studies were stopped early because of increased mortality in the treated groups. Initial results of the STAT study are promising; publication of full study details is awaited. The ATLANTIS study was terminated early because of nonstatistical efficacy at interim analysis. The NINDS and the ECASS trials were completed; only the NINDS study demonstrated significant increase in the percentage of patients with complete recovery or minimal deficit at 3 months, without significant difference in mortality in the treated group.
Conclusion:
This review supports the use of intravenous thrombolytic therapy for ischemic stroke using tPA at a dose of.9 mg/kg body weight and a "golden window" treatment time of 3 hours. Administration without strict adherence to protocol, even within this time frame, may shift the benefit/risk profile of tPA. We recommend the treating physician have rapid access to CT scanning and to collaboration with individuals experienced in the evaluation of stroke and CT interpretation.