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Review
. 2017 Aug;17(8):60.
doi: 10.1007/s11910-017-0767-5.

Controversies in Thrombolysis

Peter A G Sandercock  1 , Stefano Ricci  2
Affiliations
Review

Controversies in Thrombolysis

Peter A G Sandercock et al. Curr Neurol Neurosci Rep. 2017 Aug.

Abstract

Purpose of review: The purpose of the review is to examine recent evidence on the effects of intravenous thrombolysis and identify the remaining uncertainties.

Recent findings: We review the results of two large trials (the third International Stroke Trial (IST-3) and The Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED)) and the publications from the individual patient data analyses of the trials of alteplase conducted by the Stroke Thrombolysis Trialists Collaboration. Despite about a 2% risk of fatal intracerebral haemorrhage, on average, adult patients of all ages treated with 0.9 mg/kg alteplase within 4.5 h will have better long-term functional outcome. The use of a lower dose of alteplase (0.6 mg/kg) is associated with a lower risk of haemorrhage but its effect on functional outcome has not been proven to be non-inferior to standard dose therapy. Some clinicians feel confident to treat selected patients who present beyond 4.5 h or have unknown time of onset, but many also agree that the current trials and other research is needed to reliably define the optimum imaging methods and treatment eligibility criteria.

Keywords: Alteplase; Functional outcome; Imaging; Intracerebral haemorrhage; Ischaemic stroke; Thrombolytic therapy.

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Conflict of interest statement

Conflict of Interest

Peter A. G. Sandercock received a donation of drug and placebo for a pilot study and a lecture fee paid to the department from Boehringer Ingelheim.

Stefano Ricci reports a grant from Boehringer Ingelheim.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Figures

Fig. 1
Fig. 1
Estimated proportion of patients in each mRS score category with or without alteplase, according to stroke severity at baseline. An mRS of 0–1 indicates an excellent outcome: survival symptom free or with residual symptoms with no loss of activity. mRS 5–6 indicates bed bound or dead at 3–6 months. In IST-3, 125 (4.1%) of 3035 patients died between 3 and 6 months. For comparability of mRS 6 between IST-3 and the other trials (which assessed mRS scores at 3 months), these patients were reassigned an mRS of 5 for this analysis. NIHSS National Institutes of Health Stroke Scale, mRS modified Rankin Scale, IST-3 Third International Stroke Trial. Reproduced with permission, Elsevier from Stroke Thrombolysis Trialists Collaboration 2016 [••]. NNT for mRS 0–1 is 10 within 3 h, 19 from 3 to 4.5 h and 50 from 4.5 to 6 h. Reproduced from Fig. 4 in. Whiteley et al., Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis. Lancet Neurol 2016; 15: 925–33
See this image and copyright information in PMC

References

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