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Thrombolytic Therapy in Acute Ischemic Stroke
Anthony J. Furlan1, Irene L. Katzan, Louis R. Caplan
1Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195-5001, USA.
Insights
Intravenous thrombolytic therapy, including recombinant tissue-plasminogen activator (rt-PA), is approved for acute ischemic stroke but underutilized. Physician and center limitations, along with hemorrhage risks, hinder widespread adoption.
Area of Science:
- Neurology
- Cardiology
- Emergency Medicine
Background:
- Intravenous thrombolytic therapy is approved for acute ischemic stroke in major regions.
- Guidelines recommend recombinant tissue-plasminogen activator (rt-PA) within 3 hours of stroke onset, with specific contraindications.
- Despite approval, rt-PA use remains low (<5%) in the United States.
Purpose of the Study:
- To review the current status and challenges of intravenous thrombolytic therapy for acute ischemic stroke.
- To highlight the gap between rt-PA eligibility and actual patient treatment.
- To identify barriers to the adoption of thrombolytic therapy in clinical practice.
Main Methods:
- Review of published guidelines and clinical practice data regarding rt-PA administration.
- Analysis of factors influencing physician and medical center willingness to administer thrombolysis.
- Assessment of the risks associated with thrombolytic therapy, specifically hemorrhage and edema.
Main Results:
- Only a small percentage of eligible acute ischemic stroke patients receive rt-PA.
- Significant risks of fatal brain hemorrhage (5-10%) are associated with thrombolysis.
- Many healthcare providers and institutions lack the resources or willingness to administer thrombolytic drugs.
Conclusions:
- Despite its efficacy, rt-PA treatment for acute ischemic stroke faces significant underutilization.
- Barriers include physician hesitancy, institutional unpreparedness, and the inherent risks of hemorrhage.
- Strategies to improve rt-PA administration are needed to increase access to this critical stroke treatment.
Abstract:
The use of intravenous thrombolytic therapy for the treatment of patients with acute ischemic stroke is now approved in the United States, Canada, Germany, and the European Union. Guidelines published in 1996 from the American Heart Association and American Academy of Neurology committees recommended intravenous administration of recombinant tissue-plasminogen activator (rt-PA) (0.9 mg/kg; maximum of 90 mg) given in a 10% bolus, followed by an infusion lasting 60 minutes, to patients within 3 hours of onset of ischemic stroke. The recommendations stipulate that a computed tomography scan before the infusion should not show major infarction, mass effect, edema, or hemorrhage. Yet, only a small fraction of eligible patients (< 5%) have received rt-PA during the 7 years since its approval in the United States. Although effective, thrombolysis carries an important risk (5% to 10%) of brain hemorrhage and edema that can prove fatal. Many physicians and medical centers are not presently equipped or willing to give thrombolytic drugs for stroke treatment.