Views on the use of tissue plasminogen activator in acute ischemic stroke: a state-wide survey among neurologists and emergency medicine physicians in Indiana

Current perspectives on the use of intravenous recombinant tissue plasminogen activator (tPA) for treatment of acute ischemic stroke

In 1995, the NINDS (National Institute of Neurological Disorders and Stroke) tPA (tissue plasminogen activator) Stroke Study Group published the results of a large multicenter clinical trial demonstrating efficacy of intravenous tPA by revealing a 30% relative risk reduction (absolute risk reduction 11%-15%) compared with placebo at 90 days in the likelihood of having minimal or no disability. Since approval in 1996, tPA remains the only drug treatment for acute ischemic stroke approved by the US Food and Drug Administration. Over the years, an abundance of research and clinical data has supported the safe and efficacious use of intravenous tPA in all eligible patients. Despite such supporting data, it remains substantially underutilized. Challenges to the utilization of tPA include narrow eligibility and treatment windows, risk of symptomatic intracerebral hemorrhage, perceived lack of efficacy in certain high-risk subgroups, and a limited pool of neurological and stroke expertise in the community. With recent US census data suggesting annual stroke incidence will more than double by 2050, better education and consensus among both the medical and lay public are necessary to optimize the use of tPA for all eligible stroke patients. Ongoing and future research should continue to improve upon the efficacy of tPA through more rapid stroke diagnosis and treatment, refinement of advanced neuroimaging and stroke biomarkers, and successful demonstration of alternative means of reperfusion.

Emergency physician and stroke specialist beliefs and expectations regarding telestroke

BACKGROUND AND PURPOSE

Telestroke has been effective in the management of acute ischemic stroke. This study characterizes and compares stroke specialist (SS) and emergency physician (EP) perceptions of telestroke and identifies barriers preventing increased implementation.

METHODS

A survey was developed and distributed nationwide to 382 SSs through an online survey system and in paper form to 226 EPs attending the 2008 American College of Emergency Physicians national conference.

RESULTS

Stroke specialists perceived themselves to be more knowledgeable about telemedicine and telestroke (P<0.001 and P=0.010, respectively). A large majority of physicians in both specialties either strongly agreed or agreed that telestroke will reduce geographical differences in stroke management and that it is superior to telephone consultation. EPs perceived patient preference (P<0.001), recombinant tissue plasminogen activator side effects (P<0.001), level of technology (P=0.005), and recombinant tissue plasminogen activator not the standard of care (P<0.001) to be more significant obstacles to increased implementation of telestroke than SSs. However, SSs found increased personal work to be a greater barrier than EPs (P<0.001).

CONCLUSIONS

SSs and EPs report positive beliefs regarding telestroke; however, perceived obstacles exist to implementation. Differences between barriers perceived by EPs and SSs need to be addressed to enhance acute ischemic stroke treatment.

Tissue plasminogen activator use: evaluation and initial management of ischemic stroke from an Iowa hospital perspective

Despite its efficacy for acute ischemic stroke, tissue plasminogen activator (rt-PA) is reported as used in less than 5% of patients with stroke. This study assessed the rate of intravenous rt-PA use in a community hospital and identified factors influencing rt-PA use. A retrospective chart review revealed a total of 464 patients presenting to the emergency department with a primary diagnosis of stroke from January 2000 through June 2002. Records were sorted into 3 groups: those presenting to the emergency department within 3 hours, 3 to 6 hours, and 6 hours or more of symptom onset. Each record was reviewed using National Institute of Neurologic Disorders and Stroke thrombolytic therapy criteria. Primary measures were rate of intravenous rt-PA use and reasons for not receiving rt-PA. Of the 464 patients with stroke who presented to the emergency department during the 30-month period, 99 arrived in less than 3 hours, 22 between 3 and 6 hours, and 343 greater than 6 hours. A total of 13 (2.8% of all patients with stroke or 13% of those presenting within 3 hours) received rt-PA. All patients meeting criteria received rt-PA. Rapidly improving or minor symptoms and difficult to control or elevated blood pressure were the most common reasons for not using rt-PA. Of the patients arriving within the 3-hour window, 14 were excluded by time factors. We conclude from this study that rt-PA can be effectively used in community hospitals and that use likely exceeds previously quoted national rates when based on a more appropriate measure of eligibility criteria as opposed to total presenting patients with stroke.

Protocol violations in community-based rTPA stroke treatment are associated with symptomatic intracerebral hemorrhage

BACKGROUND

Recombinant tissue plasminogen activator (rTPA) is an established treatment for acute ischemic stroke. The rate and type of protocol violations in rTPA use and their effect on patient outcomes in this setting are not well understood.

OBJECTIVE

The objective of this study was to examine associations between protocol violations and outcomes in community-based rTPA use.

METHODS

We reviewed medical records of stroke patients treated with rTPA in 10 acute-care hospitals in Indianapolis from July 1996 to February 1998 and assessed complications and outcome. Retrospective National Institute of Health Stroke Scale (on admission and discharge), Canadian Neurological Scale, and length of hospital stay were calculated. Appropriate use of rTPA was determined by the National Institute of Neurological Disorders and Stroke (NINDS) protocol.

RESULTS

Fifty patients (mean age, 66 years; 76% white; 56% men) were treated by general neurologists (70%), stroke neurologists (24%), or emergency physicians (6%). Mean times to hospital arrival, brain CT, and start of rTPA infusion were 44, 86, and 141 minutes, respectively. In-hospital mortality rate was 10% (4 intracerebral hemorrhage [ICH], 1 cardiogenic shock). Complications were more frequent among patients with protocol violations (n=8) compared with those without all hemorrhages (75% versus 10%, P:<0.001), symptomatic ICH (38% versus 5%, P:<0.02), and ICH attributable to rTPA, occurring within 36 hours (38% versus 2.4%, P:<0.01), respectively.

CONCLUSIONS

NINDS protocol violations are relatively common and are associated with symptomatic cerebral and systemic hemorrhages. When the NINDS protocol is strictly followed, hemorrhage rates in community-based rTPA use are similar to those in the NINDS trial.