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Thrombolytic therapy for acute ischemic stroke

Published online by Cambridge University Press:  21 May 2015

Canadian Association of Emergency Physicians Committee on Thrombolytic Therapy for Acute Ischemic Stroke
Canadian Association of Emergency Physicians Committee on Thrombolytic Therapy for Acute Ischemic Stroke
Affiliation:
For a complete list of the Committee members, see Appendix 1.

Abstract

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Current evidence suggests that, in a small subset of acute stroke patients who can be treated within 3 hours of symptom onset, the administration of tissue plasminogen activator (tPA) confers a modest outcome benefit, but that this benefit is associated with an increased risk of intracranial hemorrhage that can be severe or fatal. The data show that tPA therapy must be limited to carefully selected patients within established protocols. Further evidence is necessary to support the widespread application of stroke thrombolysis outside research settings. Until it is clear that the benefits of this therapy outweigh the risks, thrombolytic therapy for acute stroke should be restricted to use within formal research protocols or in monitored practice protocols that adhere to the NINDS (the rt-PA Stroke Study Group trial of the National Institute of Neurological Disorders and Stroke) eligibility criteria. All data on protocol compliance and patient outcomes should be collated in a central Canadian registry for the purposes of tracking safety and efficacy.

Stroke thrombolysis should be limited to centers with appropriate neurological and neuro-imaging resources that are capable of administering treatment within 3 hours. In such centres, emergency physicians should identify eligible patients, initiate low risk interventions and facilitate prompt computed tomography. Only physicians with demonstrated expertise in neuroradiology should interpret head CT scans used to determine whether to administer thrombolytic agents to stroke patients. Neurologists should be directly involved prior to the thrombolytic administration.

Type
CAEP Position Statement • Déclaration de Position De L’ACMU
Information
Canadian Journal of Emergency Medicine , Volume 3 , Issue 1 , January 2001 , pp. 8 - 12
Copyright
Copyright © Canadian Association of Emergency Physicians 2001

References

1.Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995;333(24):1581–7.Google Scholar
2.Randomised controlled trial of streptokinase, aspirin, and combination of both in treatment of acute ischaemic stroke. Multicentre Acute Stroke Trial–Italy (MAST-I) Group. Lancet 1995;346: 1509–14.Google Scholar
3.Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial — Europe Study Group. N Engl J Med 1996;335:145–50.Google Scholar
4.Donnan, GA, Davis, SM, Chambers, BR, Gates, PC, Hankey, GJ, McNeil, JJ, et al. Streptokinase for acute ischemic stroke with relationship to time of administration. JAMA 1996;276:961–6.CrossRefGoogle ScholarPubMed
5.Hacke, W, Kaste, M, Fieschi, C, Toni, D, Lesaffre, E, von Kummer, R, et al. Intravenous thrombolysis with recombinant tissue plas-minogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study. JAMA 1995;274:1017–25.CrossRefGoogle Scholar
6.Hacke, W, Kaste, M, Fieschi, C, von Kummer, R, Davalos, A, Meier, D, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European–Australasian Acute Stroke Study Investigators. Lancet 1998;352:1245–51.CrossRefGoogle ScholarPubMed
7.Furlan, A, Higashida, R, Wechsler, L, Gent, M, Rowley, H, Kase, C, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II Study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999;282:2003–11.CrossRefGoogle ScholarPubMed
8.Clark, WM, Wissman, S, Albers, GW, Jhamandas, JH, Madden, KP, Hamilton, S.Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. JAMA 1999;282(21):2019–26.CrossRefGoogle ScholarPubMed
9.Norris, JW, Buchan, A, Cote, R, Hachinski, V, Phillips, SJ, Shuaib, A, et al. Canadian guidelines for intravenous thrombolytic treatment in acute stroke. A consensus statement of the Canadian Stroke Consortium. Can J Neurol Sci 1998;25(3):257–9.CrossRefGoogle ScholarPubMed
10.von Kummer, R, Allen, KL, Holle, R, Bozzao, L, Bastianello, S, Manelfe, C, et al. Acute stroke: usefulness of early CT findings before thrombolytic therapy. Radiology 1997;205:327–33.CrossRefGoogle ScholarPubMed
11.Schriger, DL, Kalafut, M, Starkman, S, Krueger, M, Saver, JL.Cranial computed tomography interpretation in acute stroke: physician accuracy in determining eligibility for thrombolytic therapy. JAMA 1998;279:1293–7.CrossRefGoogle ScholarPubMed
12.O’Connor, RE, McGraw, P, Edelsohn, L.Thrombolytic therapy for acute ischemic stroke: why the majority of patients remain ineligible for treatment. Ann Emerg Med 1999;33:9–14.CrossRefGoogle ScholarPubMed
13.Zweifler, RM, Drinkard, R, Cunningham, S, Brody, ML, Rothrock, JF.Implementation of a stroke code system in Mobile, Alabama: diagnostic and therapeutic yield. Stroke 1997;28:981–3.CrossRefGoogle ScholarPubMed
14.Libman, RB, Wirkowski, E, Alvir, J, Rao, TH.Conditions that mimic stroke in the emergency department: implications for acute stroke trials. Arch Neurol 1995;52(11):1119–22.CrossRefGoogle ScholarPubMed
15.Leys, D, Lucas, C, Devos, D, Mounier-Vehier, F, Godefroy, O, Pruvo, JP, et al. Misdiagnoses in 1,250 consecutive patients admitted to an acute stroke unit. Cerebrovasc Dis 1997;7 (Suppl 5):284–8.Google Scholar
16.Allder, SJ, Moody, AR, Martel, AL, Morgan, PS, Delay, GS, Gladman, JR.Limitations of clinical diagnosis in acute stroke. Lancet 1999;354:1523–6.CrossRefGoogle ScholarPubMed
17.Albers, GW, Bates, VE, Clark, WM, Bell, R, Verro, P, Hamilton, SA.Intravenous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA 2000;283(9):1145–50.CrossRefGoogle ScholarPubMed
18.Katzan, IL, Furlan, AJ, Lloyd, LE, Frank, JI, Harper, DL, Hinchey, JA, et al. Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience. JAMA 2000; 283(9):1151–8.CrossRefGoogle ScholarPubMed