'Time Is Brain'

A Look at tPA Time to Treatment

Mark J. Alberts, MD


July 09, 2013

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Hello. I am Dr. Mark Alberts. Welcome to this Medscape stroke update. Today I would like to discuss an article very recently published in JAMA by Saver and colleagues.[1] These investigators used a very large get-with-the-guidelines stroke database to look at the association between outcomes and treatment delays with IV tPA (tissue plasminogen activator) therapy for acute ischemic stroke. This large study examined over 58,000 patients. They looked at the use of IV tPA within 4.5 hours of stroke onset.

They found that patients treated earlier vs later within the time period had significantly improved outcomes, including a 26% relative risk reduction for in-hospital mortality and a 28% relative risk reduction in symptomatic hemorrhage, in particular symptomatic intracerebral hemorrhage. Furthermore, for every 1000 patients treated sooner rather than later, 18 additional patients were better able to ambulate and 8 additional patients were functionally independent. This is very important.

They did look at confounding factors, just to make sure there were no underlying biases. As you might expect, patients with the most severe strokes, as judged by a higher NIH Stroke Scale score, tended to come to the hospital sooner for therapy compared with those with lower stroke scale scores. Thus, the better outcomes in the patients who were treated sooner rather than later cannot be explained by a supposition that they had less severe strokes. The study also found that patients who came in by ambulance tended to present sooner and have better outcomes than those who came in by other modes of transportation.