Time to drop scepticism on tPA for acute ischaemic stroke

Two Australian stroke experts have argued strongly for the increased use of tPA fibrinolysis in patients with acute ischaemic stroke, and called for an end to scepticism among emergency physicians about the benefits of the treatment. Professors Stephen Davis and Geoffrey Donnan, in a commentary to be published in Stroke, said the ECASS III study had shown benefits from alteplase administered up to 4.5 hours after symptom onset. Treatment was associated with a 7% reduction in disability at 90 days. Findings from ECASS III were consistent with meta-analyses of previous fibrinolysis trials and registry data, and added substantially to the weight of evidence, they said. There were immediate clinical implications of the study, the authors noted. First, there was unequivocal support for extending the time window between symptom onset and treatment from 3 hours to 4.5 hours. “Second, these results should remove any doubt from the sceptics, particularly in emergency medicine, concerning the therapeutic efficacy and relative safety of tPA in ischaemic stroke,” they said. The underlying message remained unchanged: that “time is brain” and early treatment achieved better results. “It is better to treat within 3 than 4.5 hours, and even better within 90 minutes, of onset. Earlier treatment is associated with increased therapeutic effect and this should be the goal of all stroke clinicians and underpin the design of acute stroke systems,” they concluded. Uptake of tPA for acute ischaemic stroke varied widely, from 20% in some expert centres to only 1-3% in many other hospitals. Stroke 2009; published online before print...