Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke

Abstract

Background and Purpose —In the United States, tissue plasminogen activator (tPA) was approved for treatment of acute ischemic stroke in 1996. Its use has only recently been approved in Canada. We sought to evaluate the safety, feasibility, and efficacy of treatment in a Canadian hospital setting. Methods —A combined retrospective and prospective review is presented of 46 consecutive patients treated with intravenous tPA at our hospital with a treatment protocol similar to that of the National Institute of Neurological Disorders and Stroke (NINDS) trial. Results —Symptomatic intracranial hemorrhage at 36 hours occurred in 1 patient (2.2%). The median time to treat was 165 minutes, with a median “door-to-needle” time of 84 minutes. Compared with patients presenting initially at our hospital, patients transferred from another institution for tPA therapy were treated closer to the 3-hour time window (mean 173 versus 148 minutes, P <0.001) but had a shorter door-to-needle time (43 versus 102 minutes, P <0.001). For every 10 minutes closer to the 3-hour time window that any patient arrived at the hospital, 7 minutes was saved in the door-to-needle time (correlation coefficient 0.9, P <0.001). Patient outcome did not differ from that in the NINDS trial ( P >0.75). Conclusions —Our safety and patient outcome data compare favorably with NINDS and Phase IV data. Although a 3-hour treatment window was feasible, the median door-to-needle time lengthened as more treatment time was available and the door-to-needle time was beyond recommended standards. This review has prompted changes in our community to improve treatment efficiency.

Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study

“…3), and was similar to rates in other reported series. [26][27][28][29][30][31][32][33][34][35][36] Serious adverse events occurred in 75 (6.6%) of the patients (95% CI 5.2%-8.2%) ( Table 3). Of the 52 (4.6%) who had a symptomatic intracranial hemorrhage, 39 (75%) died in hospital.…”

Pre- and In-Hospital Delays From Stroke Onset to Intra-arterial Thrombolysis

“…This phenomenon has also been observed in intravenous tPA studies when the 3-hour limit was close. 18,28 Demographic factors such as sex and age did not influence the time delay to treatment. Patients who were already familiar with the signs and symptoms of stroke because of previous cerebrovascular events did not arrive faster in the ED of our stroke center.…”

“…12,14,[17][18][19][20][21] It has also been shown that educational programs for both the public and physicians increase the number of patients arriving at the hospitals within the time limits for thrombolysis. 22 In US stroke centers, up to 59% of the patients who presented within 24 hours of symptom onset arrived within 3 hours.…”

“…Similar analyses have already been performed for intravenous treatment. [17][18][19][20]27 Patients who were transferred directly to our stroke center were mostly residents of Bern or an area close to that vicinity. Their mean prehospital delay was 99 minutes.…”

Qualitative Data Collection and Analysis Methods: The INSTINCT Trial

“…[17][18][19][20][21][22] Studies elsewhere have demonstrated that community and academic hospitals can deliver tPA effectively. 20,[23][24][25][26][27][28][29][30] However, numerous internal and external barriers exist to expanding delivery more broadly in patients with stroke. 31,32 Work published elsewhere found that a combination of community and professional education increased thrombolytic use in patients with stroke, from a preintervention rate of 2.2% to a postintervention rate of 11.3% (p = 0.007), with the data suggesting that the professional education component was the critical element in increasing use.…”