Extending thrombolysis to 4·5–9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data

Patients with ischaemic stroke 4·5–9 h from stroke onset or wake-up stroke with salvageable brain tissue who were treated with alteplase achieved better functional outcomes than did patients given placebo. The rate of symptomatic intracerebral haemorrhage was higher with alteplase, but this increase did not negate the overall net benefit of thrombolysis.

 NYT calls this a 'gold-standard' of stroke treatment. But some experts are pushing back

The treatment is not perfect. Patients generally must be treated within three hours of the onset of symptoms, and TPA carries a risk of brain hemorrhage. However, Kolata writes that rates of cerebral hemorrhage have dropped over the years as doctors have gained more experience.

 Thrombolysis in Acute Ischemic Stroke: Now We Have No Positive RCTs

One of the most hotly debated topics in emergency medicine is the use of systemic thrombolysis in acute ischemic stroke. There are only two randomized clinical trials that demonstrate benefit in neurologic outcomes: NINDS-II and ECASS-III

 Window for IV Thrombolysis in Stroke May Stay Open Twice as Long With Imaging Selection

The prematurely halted EXTEND trial suggests benefits can be seen in patients who present within 9 hours or who wake up with a stroke.

For Many Strokes, There’s an Effective Treatment. Why Aren’t Some Doctors Offering It?

“We felt the data was so strong we didn’t have to explain it” in the published report, he said. He was wrong. That groundbreaking clinical trial concluded 22 years ago, yet Dr. Lewandowski and others are still trying to explain the data to a powerful contingent of doubters. The skeptics teach medical students that T.P.A.is dangerous, causing brain hemorrhages, and that the studies that found a benefit were deeply flawed. Better to just let a stroke run its course, they say.

The pharma industry has failed stroke, so doctors are looking elsewhere

The cutting-edge treatment for stroke isn’t an elegantly crafted drug or a gene therapy, but a device that works like a pipe cleaner. It’s a thin metal catheter that snakes its way up from a patient’s thigh, through their heart, and into the blood vessels of the brain, where it clears the obstruction causing the stroke. The technology, called “mechanical thrombectomy” or “endovascular therapy,” has become the preferred treatment for certain set of ischemic strokes not because it’s easy or inexpensive—it is neither of those things—but because the pharmaceutical industry has largely failed to develop a drug that works as well.

The Use of Thrombolysis as a Treatment for Acute Stroke

Yes. I hear it. A weathered and worn sigh at the sight of another article debating the pros and cons of the use of tPA in acute ischaemic stroke. Surely, you say to yourself, do we REALLY need another one? Hasn’t this issue been thrashed out and mauled until it is bleeding like an iatrogenic coagulopathy?

Thrombolytics for stroke: The evidence

The evidence for (or against) thrombolytics is important precisely because the topic is so controversial. You will hear arguments on both sides. So will your patients. It is only through a familiarity with the studies, their strengths, and their weaknesses, that you will be able to decide for yourself what the evidence really shows and guide your patients to the best decision for their circumstances.

Breaking News: The ‘Biggest, Baddest’ Controversy in EM

The American College of Emergency Physicians and the American Academy of Neurology jointly issued a new clinical policy on thrombolytics for stroke, but the new statement has done little to resolve one of the most troubling rifts in emergency medicine. The recommendations are nothing new in thrombolytics-for-stroke circles, first drawing attention after the original NINDS trial was published in 1995.

Certified Stroke Centers More Likely to Give Clot-Busting Drugs

Stroke patients are three times more likely to receive clot-busting medication if treated at a certified stroke center, according to a study in the Journal of the American Heart Association.

Evidence for thrombolytics in stroke Part 1

I’ve presented on this a couple of times but this is gonna require a few parts, so be patient with me. This is not quite a deep-dive in the SMART EM sense, more of a shallow dive you might do with a snorkel rather than a full on SCUBA.

Skepticism about thrombolytics in stroke is not unreasonable

Revascularization of ischemic tissue and rescue of a still-viable penumbra are valid therapeutic goals, but the literature in support of thrombolytics in acute ischemic stroke should not be misrepresented. Rather than endeavor to treat more patients with systemic thrombolytic therapy, further research should focus on narrowing the treatment population to those who are most likely to benefit from this intervention.

Stroke - Is the Treatment Worth the Risk?

It's sad to say that customary stroke treatment is similar to how heart attacks were treated before the 1970's. New technology is needed, not just clot busters. In the meantime know where the nearest stroke treatment center is.

Stroke Care: A Balanced Approach to the tPA Debate

The question of the safety and efficacy of alteplase (tPA) for the treatment of acute ischemic stroke (AIS) has been debated by emergency physicians (EPs) for many years. Differences of opinion have been expressed since the National Institute of Neurological Disorders and Stroke (NINDS) trial was published in 1995 showing that patients treated with alteplase were more likely to have little or no disability at 3 months compared to placebo.

The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial

Thrombolysis is of net benefit in patients with acute ischaemic stroke, who are younger than 80 years of age and are treated within 4·5 h of onset. The third International Stroke Trial (IST-3) sought to determine whether a wider range of patients might benefit up to 6 h from stroke onset.

The Debate on tPA for Ischemic Stroke at EMCrit – What Does the Research Really Say?

The proponents of tPA (Alteplase) are not trying to defend the other studies. They have a hard enough time putting a positive spin on the studies they want us to look at – just not too closely.

Thrombolysis for acute ischemic stroke: still a treatment for the few by the few

So, 6 years after NINDS, thrombolysis remains a treatment for the few by the few. How can the stroke community solve this problem? First, implement basic proven knowledge: organize inpatient stroke services, and give aspirin immediately to all aspirin-eligible patients.

Tissue plasminogen activator (tPA) for acute ischaemic stroke: why so much has been made of so little

Although advocates of the use of tissue plasminogen activator (tPA) in acute ischaemic stroke suggest that this is one of the most important advances in stroke medicine. A recent Cochrane meta-analysis also supports clinicians who choose not to use the treatment at all, and all three major emergency medicine associations in North America have declined to endorse it as standard of care.