Improved outcomes in stroke thrombolysis with pre-specified imaging criteria.

Abstract

BACKGROUND:

A 1995 National Institute of Neurological Disorders (NINDS) study found benefit for intravenous tissue plasminogen activator (tPA) in acute ischemic stroke (AIS). The symptomatic intracranial hemorrhage (SICH) rate in the NINDS study was 6.4%, which may be deterring some physicians from using this medication.

METHODS:

Starting December 1, 1998, patients with AIS in London, Ontario were treated according to NINDS criteria with one major exception; those with approximately greater than one-third involvement of the idealized middle cerebral artery (MCA) territory on neuroimaging were excluded from treatment. The method used to estimate involvement of one-third MCA territory involvement bears the acronym ICE and had a median kappa value of 0.80 among five physicians. Outcomes were compared to the NINDS study.

RESULTS:

Between December 1, 1998 and February 1, 2000, 30 patients were treated. Compared to the NINDS study, more London patients were treated after 90 minutes (p<0.00001) and tended to be older. No SICH was observed. Compared to the treated arm of the NINDS trial, fewer London patients were dead or severely disabled at three months (p=0.04). Compared to the placebo arm of the trial, more patients made a partial recovery at 24 hours (p=0.02), more had normal outcomes (p=0.03) and fewer were dead or severely disabled at three months (p=0.004).

CONCLUSIONS:

The results of the NINDS study were closely replicated and, in some instances, improved upon in this small series of Canadian patients, despite older are and later treatment. These findings suggest that imaging exclusion criteria may optimize the benefits of tPA.

• Authors: B Silver, B Demaerschalk, J G Merino, E Wong, A Tamayo, A Devasenapathy, C O'Callaghan, A Kertesz, G B Young, A J Fox, J D Spence, V Hachinski
• Journal: The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques (Can J Neurol Sci) Vol. 28 Issue 2 Pg. 113-9 (May 2001) ISSN: 0317-1671 [Print] England
• PMID: 11383934 (Publication Type: Clinical Trial, Controlled Clinical Trial, Journal Article)

Chemical References

• Fibrinolytic Agents
• Tissue Plasminogen Activator

Topics

• Acute Disease
• Aged
• Aged, 80 and over
• Brain Ischemia (diagnostic imaging, drug therapy)
• Female
• Fibrinolytic Agents (administration & dosage)
• Follow-Up Studies
• Humans
• Infarction, Middle Cerebral Artery (diagnostic imaging, drug therapy)
• Male
• Middle Aged
• Prospective Studies
• Stroke (diagnostic imaging, drug therapy)
• Thrombolytic Therapy
• Tissue Plasminogen Activator (administration & dosage)
• Tomography, X-Ray Computed
• Treatment Outcome