TPA for Stroke in the Setting of Dissection

2/16/01 (Benson)

RE: A 74 year old male with left sided chest pain and acute onset of stroke at presentation.

Question: Is thrombolytic therapy for stroke appropriate in the setting of possible aortic dissection?

NOTE: Dr. Benson picked #3 & #5

Both of these articles referenced #8.

Link Directly to Fulltext article in Ovid

<3>

Unique Identifier: 20152869

Authors: Fessler AJ. Alberts MJ.

Institution: Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.

Link Directly to Fulltext Article at Publisher

<5>

Unique Identifier: 99132460

Authors: Flemming KD. Brown RD Jr.

Link Directly to Fulltext article in Ovid

<8>

[Link Directly to Fulltext Article in OVID]

Unique Identifier: 96072885

Authors: Anonymous.

Abstract: BACKGROUND. Thrombolytic therapy for acute ischemic stroke has been approached cautiously because there were high rates of intracerebral hemorrhage in early clinical trials. We performed a randomized, double-blind trial of intravenous recombinant tissue plasminogen activator (t-PA) for ischemic stroke after recent pilot studies suggested that t-PA was beneficial when treatment was begun within three hours of the onset of stroke. METHODS. The trial had two parts. Part 1 (in which 291 patients were enrolled) tested whether t-PA had clinical activity, as indicated by an improvement of 4 points over base-line values in the score of the National Institutes of Health stroke scale (NIHSS) or the resolution of the neurologic deficit within 24 hours of the onset of stroke. Part 2 (in which 333 patients were enrolled) used a global test statistic to assess clinical outcome at three months, according to scores on the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS. RESULTS. In part 1, there was no significant difference between the group given t-PA and that given placebo in the percentages of patients with neurologic improvement at 24 hours, although a benefit was observed for the t-PA group at three months for all four outcome measures. In part 2, the long-term clinical benefit of t-PA predicted by the results of part 1 was confirmed (global odds ratio for a favorable outcome, 1.7; 95 percent confidence interval, 1.2 to 2.6). As compared with patients given placebo, patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales. Symptomatic intracerebral hemorrhage within 36 hours after the onset of stroke occurred in 6.4 percent of patients given t-PA but only 0.6 percent of patients given placebo (P < 0.001). Mortality at three months was 17 percent in the t-PA group and 21 percent in the placebo group (P = 0.30). CONCLUSIONS. Despite an increased incidence of symptomatic intracerebral hemorrhage, treatment with intravenous t-PA within three hours of the onset of ischemic stroke improved clinical outcome at three months.