Is Intraarterial tPA Within 3 Hours the Treatment of Choice for Selected Stroke Patients?

Routine provision of intraarterial tPA is unfeasible, not cost-effective, and would deflect stroke services from offering other far more effective interventions. The public health benefit of intraarterial tPA is negligible, and evidence from the screening log of the PROACT 2 trial suggests that this intervention has no prospect producing a measurable impact. In the PROACT 2 study, a total of 12 323 patients were screened, of whom 474 had angiograms to randomize 180 subjects in this trial—a “treatment” rate of <1.5%.1 A quarter of ischemic stroke is lacunar subtype, and angiography of the major vessels will be normal in these patients, yet current evidence suggests that patients with lacunar stroke also benefit from intravenous thrombolysis. Even large cities struggle to provide just one center with sufficient expertise to provide a 24-hour interventional stroke neuroradiology service. In addition to this feasibility data, …