t-PA for mild ischemic stroke: we shouldn't be afraid to treat.

摘要

Since the 1995 publication of the National Institutes of Health (NIH) randomized clinical trial and subsequent Federal Drug Administration (FDA) approval in 1996, tissue plasminogen activator (t-PA) has been widely accepted as an effective treatment strategy for the management of acute isch-emic stroke. Among the potential complications associated with intravenous t-PA administration, intracerebral hemorrhage (ICH) remains the most feared and potentially devastating complication of stroke thrombolysis. Symptomatic ICH usually occurs within the first 24-36 hours after administration. In the NIH study, 6.4% of patients showed symptomatic ICH with associated clinical deterioration in the t-PA group as compared with 0.6% in the placebo group. The mortality rate in cases of symptomatic ICH was 47%, but the overall mortality rate was lower in the t-PA group than in the placebo group (17% vs 21%) due to a reduction in non-ICH related deaths. It is this concern of post t-PA ICH, with its associated morbidity and mortality, that has given many physicians pause when considering the administration of t-PA to patients with "mild" ischemic strokes. In fact, the available data shows that some 30-40% of all patients presenting with "mild" or rapidly improving ischemic symptoms fail to receive intravenous thrombolytics despite meeting all other inclusion criteria.