Intravenous thrombolysis for acute ischaemic stroke: from randomised clinical trials to daily practice
Year: 2005
Type: dissertation
Abstract: In the Netherlands, as in most Western countries, stroke is a major contributor to the\ntotal burden of disease, with an estimated 39,600 hospital admissions, 9,000 deaths, and\napproximately 241,600 people living with the consequences of a stroke in 2009.1 Fortunately,\nimprovements are observed, stroke mortality is declining; due to a both declines\nin incidence of stroke as well as in case fatality.2,3 New treatments like thrombolysis\nfor acute ischaemic stroke are highly effective, but the main cause of increased survival\nrates after stroke is a better coordination of care, through widespread implementation\nof stroke units.4,5 Thrombolysis refers to the breakdown of blood clots by stimulating\nfibrinolysis. In 1995 a large American study on the effectiveness of thrombolysis with\nintravenous alteplase (recombinant tissue plasminogen activator, rTPA) for patients with\nacute ischaemic stroke was published. Patients treated with intravenous alteplase had\na better functional outcome at three months.6 However two European trials (MAST I\nand MAST E) had unfavourable results and the ECASS I had inconclusive results.7-9\nThe higher complication rate was attributed to a too high dose of thrombolytic and\nthe lack of improvement was attributed to the extended time window of 6 hours. In\n1998 the ECASS II trial was published, but it also showed inconclusive results.10 A few\nyears later in 2000 the Cochrane Review (including all the trials mentioned above) was\npublished and showed that thrombolytic therapy appears to result in a significant net\nreduction in the proportion of dependency or death. The relative reduction in risk of\npoor outcome, defined as a modified Rankin Score >2, was 17.5% (95% CI: 7 to 26%).11\nThe scepticism about treatment with rTPA gradually declined. Steadily but slowly, more\nand more hospitals started to treat acute ischaemic stroke patients with thrombolysis,\nbut in daily practice, several circumstances and causes put a constraint on the number of\npatients who could be treated, the most important cause being the narrow time window\nfor treatment. Taking that narrow time window into account, it was estimated that up to\n24% of the stroke patients presenting at the emergency care might be eligible for thrombolysis.\n12 In 2002-2003 however, the rate of thrombolysis in Dutch hospitals varied\nbetween 1% and 8%, with a few exceptions.13 Clearly, improvements could be made. In\naddition, concern about bleeding complications remained an issue. A European license\nfor alteplase was provided on the condition that safety and effectiveness would be monitored\nin a European registry. This resulted in the Safe Implementation of Thrombolysis\nin Stroke-Monitoring Study (SITS-MOST).
Author: Maaike Dirks
Language: English
Subfield: Clinical Neurology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W1486124474