Thrombolytic Therapy for Acute Ischemic Stroke

See related article, pages 2279–2283 .Symptomatic intracerebral hemorrhage (SICH) risk is the factor most likely to preclude tissue plasminogen activator (tPA) use by emergency physicians. Of the 40% of respondents to the American College of Emergency Physicians survey about tPA for acute ischemic stroke who would not use tPA in the ideal setting reported that this was attributable to SICH risk.1 From the same survey, we learned that in the respondents’ minds, the highest clinically acceptable mean risk of SICH was 3.4% (compared with 6.4% risk reported in the tPA arm of the National Institute of Neurological Disorders and Stroke [NINDS] trial).The American Academy of Emergency Medicine (AAEM) has created an educational tool entitled “tPA for Stroke—Potential Benefit, Risk, and Alternatives,” dated May 3, 2007, that was circulated to its membership.2 The document was designed to help emergency physicians inform patients and family members about the pros and cons of tPA for stroke in appropriate patients. The tool emphasizes how important it is for physicians to weigh the possibility of benefit (improved function at 3 months) against the possibility of harm (severe bleeding or death). The AAEM has produced an accompanying illustration to pictorially and quantitatively convey the probabilities of “good recovery,” “poor or no recovery,” and “brain bleed and death” with and without tPA in cohort of acute ischemic stroke patients. In reviewing the potential benefit, the illustration suggests that 8 of 18 stroke patients who receive tPA will have a good recovery by 3 months after the event. This is compared to 6 of 18 stroke patients who recover substantially with good outcome without tPA. Even more importantly, in reviewing the potential risk, the illustration suggests that bleeding into the brain, with high …