Editorial

t-PA for Mild Ischemic Stroke: We Shouldn't Be Afraid to Treat

Authors: Joshua M. Ammerman, MD

Abstract

Since the 1995 publication of the National Institutes of Health (NIH) randomized clinical trial and subsequent Federal Drug Administration (FDA) approval in 1996, tissue plasminogen activator (t-PA) has been widely accepted as an effective treatment strategy for the management of acute ischemic stroke. Among the potential complications associated with intravenous t-PA administration, intracerebral hemorrhage (ICH) remains the most feared and potentially devastating complication of stroke thrombolysis. Symptomatic ICH usually occurs within the first 24–36 hours after administration.1 In the NIH study, 6.4% of patients showed symptomatic ICH with associated clinical deterioration in the t-PA group as compared with 0.6% in the placebo group. The mortality rate in cases of symptomatic ICH was 47%, but the overall mortality rate was lower in the t-PA group than in the placebo group (17% vs 21%) due to a reduction in non-ICH related deaths.2 It is this concern of post t-PA ICH, with its associated morbidity and mortality, that has given many physicians pause when considering the administration of t-PA to patients with “mild” ischemic strokes.3 In fact, the available data shows that some 30–40% of all patients presenting with “mild” or rapidly improving ischemic symptoms fail to receive intravenous thrombolytics despite meeting all other inclusion criteria.4

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References

1. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. The NINDS t-PA Stroke Study Group. Stroke 1997;28:2109–2118.
 
2. 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;333:1581–1587.
 
3. van den Berg JS, de Jong G. Why ischemic stroke patients do not receive thrombolytic treatment: results from a general hospital. Acta Neurol Scand 2009;120:157–160.
 
4. Smith EE, Abdullah AR, Petkovska I, et al. Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke. Stroke 2005;36:2497–2499.
 
5. Hassan AE, Hassanzadeh B, Tohidi V, et al. Very mild stroke patients benefit from intravenous tissue plasminogen activator without increase of intracranial hemorrhage. South Med J 2010;103:398–402.
 
6. Nedeltchev K, Schwegler B, Haefeli T, et al. Outcome of stroke with mild or rapidly improving symptoms. Stroke 2007;38:2531–2535.