tPA (Alteplase) for Ischemic Stroke
Of all of tPA's drawbacks, the most troublesome is its inadequacy against big clots, which can block large blood vessels at the base of the brain; they cause about 25 to 30 percent of all strokes - David Noonan
image by: James Herrington
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NYT calls this a 'gold-standard' of stroke treatment. But some experts are pushing back
Tissue plasminogen activator (TPA) is strongly endorsed by major medical organizations to prevent brain injury after a stroke, yet up to 30% of eligible patients don't receive it—a situation that according to the New York Times' Gina Kolata stems partly from a vocal minority who say the risks outweigh the benefits. But some experts have voiced concerns about the Times' coverage of the debate.
Why TPA is endorsed by major medical societies
More than two decades ago, a large federal clinical trial showed that TPA can prevent brain injury after a stroke by opening up blood vessels that have been blocked by clots, Kolata reports. Both the American Heart Association…
Resources
tPA Contraindications for Ischemic Stroke
Provides inclusion/exclusion criteria when deciding to use tPA on a patient with acute ischemic stroke.
Is the tPA-for-Stroke Debate Over?
Given the prevailing medicolegal climate in many states, coupled with the institutional interest in stroke center certification and the growing reach of telestroke services, holding out as a conscientious objector to the use of tPA grows ever more perilous.
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.
Going Beyond the 4.5-Hour Window for Thrombolysis in Stroke
In 2015, five landmark clinical trials in short succession showed that treatment did not need to be limited to early administration of t-PA in some patients and that intra-arterial mechanical thrombectomy within 6 hours of stroke onset further improved outcomes in patients with large artery occlusions of the proximal anterior circulation. Two years later, two other clinical trials extended the window of benefit for treatment with mechanical thrombectomy to 24 hours after stroke onset.
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.
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.
Thrombolysis in Acute Ischemic Stroke (tPA)
NINDS Trial (treated within 3hrs). Benefits: 12% absolute risk reduction benefit (NNT = 8-9) at 3 months. Lower percentage of patients who left hospital severely disabled. Comparable 3-month mortality rate (even with increased rate of ICH). Risks: 1% increase in mortality 5% increase in nonfatal intracranial hemorrhage ECASS Trial (treated within 4.5hrs). Confirmed NINDS findings even when therapeutic window extended to 4.5hr. As a result AHA/ASA now recommends tPA for patients presenting up to 4.5hr after symptom onset.
Why the Go-To Stroke Drug Can Fail
The go-to stroke drug often fails. Now doctors can slide out brain clots with wires and have new tools for other blockages.
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.
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