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Early Thrombolytic Treatment Of Acute Stroke
by Jonathan Moray, M.D., Division of Neurology
Until recently, the treatment of ischemic stroke has concentrated on the prevention of further brain insult and on rehabilitation. In December 1995, the effectiveness of Tissue Plasminogen Activator (TPA) in the treatment of acute ischemic stroke was documented by a multicenter study published in the New England Journal of Medicine. For the first time, it was shown that prompt treatment after initiation of brain ischemia could reverse neurologic deficits, presumably by re-establishing blood flow through the stenotic or occluded artery.
Early Recognition Of Symptoms
The key factor in this study was the initiation of treatment within three hours from the onset of symptoms. This requires the patient to recognize the symptoms of a stroke and promptly seek care at the closest emergency department. Equally important, emergency staff must quickly recognize the onset of acute stroke and quickly begin the work-up that is required for initiation of TPA therapy.
The Need For Protocols
To address these concerns, we have drafted a protocol for emergency department and hospital staff for Merrimack Valley hospitals. The protocol emphasizes the need to initiate treatment within three hours, as studies have shown thrombolysis therapy to be ineffective in acute ischemic stroke treated after this time frame. Also important is the need to exclude intracranial hemorrhage, other potential bleeding complications, and the patient's recent use of anticoagulants. Our protocol calls for discussion of risks of the therapy, including brain hemorrhage, which was fatal in 3% of the study population. Consultation with a neurologist and discussion with both patient and family is strongly advised. This new treatment is not for all stroke victims.
Prompt And Well-Coordinated Care Critical For TPA Benefits
Recent studies from Europe show that patients are not getting to emergency departments fast enough for appropriate initiation of TPA therapy. Much of this delay is attributed to a lack of education of the signs of a stroke. To this end, we now emphasize to our patients the important signs of stroke and the need for prompt evaluation. Through a multifaceted approach emphasizing patient education on the signs of stroke, physician education on the appropriate uses of TPA, and the development of protocols with emergency departments, thrombolytic therapy can have a positive impact on a significant number of stroke patients.
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