Dr. Devin R. Harris (biography and disclosures)
What I did before
The management of acute ischemic stroke in the emergency department has been a contentious issue since the publication of the NINDS trial showing that thrombolysis is beneficial in selected patients, if given under three hours from onset1. This trial has received considerable debate, largely due to the fact that it was a single randomized trial of 624 patients that significantly changed how acute ischemic strokes were treated – but the therapy potentially had significant, severe side effects.
Opinion leaders in emergency medicine were largely against this therapy, due to the fact it was a single trial with modest benefit, from specialized centers (not reproducible in most institutions), with significant baseline differences between the intervention and control groups, and that it excluded older patients.2-4 Arguably, hesitation in adopting the widespread application of thrombolysis for acute ischemic stroke as standard of care had legitimate grounds, prior to September 2008.
What changed my practice
In September 2008, the ECASS III trial was published, that confirmed and reinforced the effectiveness of thrombolysis (namely alteplase) in treating acute ischemic stroke.5 This was a study of 821 patients, randomized to receive alteplase or placebo, between 3 and 4.5 hours after the onset of a stroke. Set in Europe, the median time to administration of alteplase was 4 hours. 52.4% of patients given alteplase versus 45.2% given placebo had a ‘favorable outcome’ (defined as little or no disability) (95% confidence interval 1.02 to 1.76; p=0.04). Despite the fact that the incidence of any intracranial hemorrhage and symptomatic intracranial hemorrhage was significantly higher in the alteplase group than the control group; mortality did not differ between the two groups (7.7% mortality in alteplase versus 8.4% in control; p=0.68).
This trial was the first randomized trial since the NINDS trial to show benefit from the administration of a thrombolytic in acute ischemic stroke, and extended the time window of therapy up to 4.5 hours after the onset of stroke symptoms.
What I do now
As an emergency physician, the management of patients with acute ischemic stroke has changed significantly.
1. Public awareness and activation of emergency health services: The largest reason for ineligibility of administration of a thrombolytic in acute ischemic stroke is time delay; patients arrive too late and do not call 9-1-1. Education of the public, and targeted education of patients at high risk of stroke by their primary care physicians, could increase the number of stroke patients who arrive to emergency departments within the time window for assessment. Family physicians should emphasize that patients presenting with or calling in with features to suggest a stroke should be immediately triaged to the emergency department, rather than waiting to get into the family physician’s office.
2. “Code Stroke” Triage: Acute stroke in the emergency department is now treated with the highest urgency. Often, emergency department staff and stroke teams are notified by pre-hospital personnel, prior to patient arrival. Assessments are immediate upon arrival and stroke patients are rapidly taken to the CT scanner. In almost all institutions, the decision to thrombolyse patients is a shared decision between patients, caregivers, and treating physicians.
3. The British Columbia Stroke Strategy (BCSS) Telestroke Project:6 Certain emergency departments on Vancouver Island and in Fraser Valley are linked by videoconferencing capabilities to consulting stroke neurologists at the Victoria General Hospital and Vancouver Hospital, allowing for real-time examination of patients, review of imaging, and shared thrombolysis decision making.
Bottom Line: Thombolysis for acute ischemic stroke is a small component of comprehensive acute stroke therapy. However, there now should be no debate into its effectiveness and the widespread adoption of its use in carefully selected patients should be supported.
References: (Note: Article requests might require a login ID with the BC College of Physicians website or UBC)
1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-8. (View article with CPSBC or UBC)
2. Hoffman JR. Should Physicians Give Tpa to Patients with Acute Ischemic Stroke? Against: And just what is the emperor of stroke wearing? West J Med 2000; 173(3): 149–150. (View article with CPSBC or UBC)
3. Hoffman JR, Schriger DL. A graphic reanalysis of the NINDS Trial. Ann Emerg Med 2009; 54(3): 329-36. (View article with UBC)
6. The British Columbia Stroke Strategy: Telestroke Project. Online: http://www.bcstrokestrategy.ca/emergencyAcuteCare/telestroke/index.html (Accessed: October 22, 2010). (View article)