Thrombolysis in acute ischaemic stroke: a guide to patient selection

Thrombolysis should be a routine treatment for selected patients with acute ischaemic stroke and shows promise in a much larger group of patients. This recommendation is based on data from two completed meta-analyses: the Cochrane Library and the rt-PA Study Group individual patient meta-analysis. In patients with ischaemic stroke, treatment with alteplase (recombinant tissue plasminogen activator; rt-PA) is associated with a non-significant excess of deaths, equivalent to about 19 extra deaths per 1000 treated. Furthermore, thrombolysis, regardless of which drug is used, definitely increases the odds of fatal intracranial haemorrhage by 4-fold. However, despite these risks, thrombolysis with alteplase reduces the odds of death or disability, with the benefit being equivalent to about 55 extra independent survivors per 1000 treated. Unfortunately, there are currently too few data to provide a comprehensive guide to patient selection. The available data suggest that younger patients (<80 years of age) who can be treated with alteplase within 3 hours of stroke onset have the most to gain, equivalent to about 100 more independent survivors per 1000 treated. The role of thrombolysis beyond 3 hours, in those with more extensive CT scan ischaemic change, and patients >80 years of age needs further evaluation. In summary, thrombolysis with alteplase is now an established treatment for acute ischaemic stroke, but clinicians need to cooperate in terms of enrolling more patients in further trials if we are to get the most out of this important treatment.