View from the emergency department on tPA

The American Heart Association (AHA) calls tPA the “gold standard” for treating ischemic strokes. AHA guidelines for the early management of acute ischemic stroke call for administering tPA as quickly as possible.

Emergency physician Jeff A. Spain, M.D., has seen firsthand what a difference tissue plasminogen activator (tPA) can make in the treatment of ischemic strokes. Spain witnessed a stroke patient suffering from hemiplegia able to regain the use of his limbs before leaving the emergency department.

“The main thing is rapid assessment,” Dr. Spain said. “The goal is to give tPA as quickly as possible if they meet the criteria.”

The criteria allow for administering tPA up to 4½ hours after symptom onset, he said, if the CT scan rules out an intracranial bleed. To determine when the symptoms began, hospital staff will question the patient, family members or others who might know.

If it’s been more than 4½ hours since the symptoms began, Dr. Spain said the criteria call for mechanical intervention with a neurosurgeon. In that case, he said they’ll use a CT angiogram to look for a large vessel occlusion.

The American Heart Association (AHA) calls tPA the “gold standard” for treating ischemic strokes. AHA guidelines for the early management of acute ischemic stroke call for administering tPA as quickly as possible.

In fact, research presented at the American Stroke Association’s 2017 International Stroke Conference found that a mobile stroke unit, with a portable CT scan and a neurologist in person or by telemedicine, was ideal because tPA could be administered in patients with ischemic stroke even before transport to the hospital.

Lead researcher May Nour, M.D., Ph.D., summed up the results this way: “Faster treatments yield better outcomes.”

The drug tPA gained widespread acceptance after the landmark 1995 National Institute of Neurological Disorders and Stroke (NINDS) trial. The trial found tPA posed no greater mortality risk versus the placebo and did much better in reducing disability.

The study, published in the New England Journal of Medicine, found that patients receiving tPA were 31 percent more likely to have minimal or no disability after 30 days. The following year, tPA was approved by the FDA.

When a stroke patient comes to the emergency department, Dr. Spain consults with a stroke neurologist and the patient or family members before administering tPA. The drug carries a small risk of intracerebral hemorrhage.

The NINDS trial found tPA increased the risk of a symptomatic intracerebral hemorrhage 6.4 percent versus 1 percent for the control.

A follow-up analysis acknowledged this additional risk, but it concluded patients had a better chance at normal or near-normal function three months after their strokes — even after accounting for the chance of intracerebral hemorrhage.

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