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Thrombolysis (different doses, routes of administration and agents) for acute ischaemic stroke
Insights
Higher doses of thrombolytic therapy for acute ischemic stroke increase fatal intracranial hemorrhage risk. Evidence is insufficient to determine optimal doses, agents, or administration routes for effectiveness.
Area of Science:
- Neurology
- Cardiology
- Pharmacology
Background:
- Thrombolytic therapy is a proven treatment for acute myocardial infarction.
- Meta-analyses indicate a potential net benefit of thrombolysis in acute ischemic stroke.
- Understanding optimal thrombolytic strategies is crucial for stroke management.
Purpose of the Study:
- To evaluate the efficacy and safety of different thrombolytic agents and regimens in acute ischemic stroke.
- To compare various doses, agents, and routes of administration for thrombolytic therapy.
- To synthesize evidence from randomized controlled trials on thrombolysis for ischemic stroke.
Main Methods:
- Systematic review and meta-analysis of randomized and quasi-randomized controlled trials.
- Searched major databases (Cochrane Stroke Group, MEDLINE, EMBASE) and handsearched journals.
- Independent assessment of trial eligibility, quality, and data extraction by two reviewers.
Main Results:
- Ten trials involving 1641 patients were included; allocation concealment was often poorly described.
- Higher doses of thrombolytic agents were associated with a threefold increase in fatal intracranial hemorrhages (OR 3.25).
- No significant differences were found in early or late mortality between lower and higher doses, nor between different thrombolytic agents or routes of administration.
Conclusions:
- Limited data suggest higher thrombolytic doses may increase bleeding risk in acute ischemic stroke.
- Current evidence is insufficient to determine the most effective thrombolytic dose, agent, or route.
- Further high-quality trials are needed to establish optimal thrombolytic strategies for ischemic stroke.
Background:
Thrombolytic therapy is effective for acute myocardial infarction, a disease with some similarities to acute ischaemic stroke. Meta-analyses suggest a net benefit in acute ischaemic stroke.
Objectives:
To assess different thrombolytic agents, and different regimens, in acute ischaemic stroke.
Search Strategy:
We searched the Cochrane Stroke Group trials register (last searched to June 2003), MEDLINE (1966 to July 2003) and EMBASE (1980 to July 2003). We handsearched four Japanese journals, contacted researchers and pharmaceutical companies, and attended relevant conferences.
Selection Criteria:
Randomised and quasi-randomised trials of different doses of a thrombolytic agent, or different agents, or the same agent given by different routes, in people with confirmed acute ischaemic stroke.
Data Collection And Analysis:
Two reviewers independently assessed trial eligibility and quality, and extracted the data.
Main Results:
Ten trials involving 1641 patients, 8 conducted in Japan, 1 in China and 1 in the USA, were included. Concealment of allocation was poorly described. Different doses (of tissue plasminogen activator or urokinase) were compared in seven trials (n = 1072 patients). Different agents (tissue plasminogen activator versus urokinase; tissue-cultured urokinase versus conventional urokinase) were compared in three trials (n = 688 patients). One trial compared different routes of administration (intravenous plus intraarterial tissue plasminogen activator versus intraarterial tissue plasminogen activator alone, n = 35 patients). As some trials compared different agents and different doses, some patients contributed to two analyses. A higher dose of thrombolytic therapy was associated with a three-fold increase in fatal intracranial haemorrhages (Odds ratio (OR) 3.25, 95% confidence interval (CI) 1.32 to 7.97) compared with a lower dose of the same agent (based on 16 events among 539 higher-dose patients and 4 events among 533 lower-dose patients in 7 trials). There was no statistically significant difference in early (OR 1.01, 95% CI 0.58 to 1.74) or late (OR 0.94, 95% CI 0.58 to 1.53) deaths between lower and higher doses. Data were inadequate to assess the effect of dose on functional outcome. No statistically significant difference was shown between different thrombolytic agents tested. The data from the pilot trial comparing different routes of administration were inconclusive.
Reviewers' Conclusions:
These scant data suggest that higher doses of thrombolytic agents may lead to higher rates of bleeding. However, the evidence is inadequate to conclude whether lower doses of thrombolytic agents are more effective than higher doses, or whether one agent is better than another, or which route of administration is the best, in acute ischaemic stroke.
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