16 September 2008

Four and a half hours

I was unhappy to wake yesterday to see this headline in my inbox:

Researchers say tPA can safely be used four-and-a-half hours after stroke.

There has long been a disconnect between the promise and marketing of tPA and its real-world value and usage. It's almost every day I see a billboard or hear a public service announcement on the radio urging people to get to the ER immediately after onset of a stroke. Of course, I fully support this kind of messaging, but the sad thing is that of the many many patients with strokes I see in the ER, the overwhelming majority are not candidates for tPA. The most common exclusion is the time interval, but many are excluded due to other factors -- age, blood pressure, trauma, vague or changing symptoms, or the absence of stroke symptoms severe enough for the benefit to exceed the risk.

And that's the rub: there is risk with tPA, a significant risk, and depending how you slice the data, the benefit in many cases is minimal.

For this reason, I think I am like most ER doctors in that in many cases of someone presenting with a stroke, I "look for the exclusionary criteria." Only in really clear-cut cases -- a severe, disabling benefit in an otherwise functional person presenting in less than 120 minutes --
am I enthusiastic about recommending the clot-buster. Otherwise, I offer the patient and their family the option, along with the data, and allow them to make an informed decision, but I am reluctant to endorse the use of tPA. Taking a smallish stroke and having it undergo hemorrhagic conversion is an awful thing. Since the mortality is almost the same, and the outlook for functional recovery is comparable (though not quite equal) with and without tPA, my feeling is that it is best reserved for cases where the benefit is clear and compelling. Regardless of the situation, it winds up being a nuanced, complex decision in each and every case, with very high stakes for the patient.

And let's not forget that there are hordes of personal injury attorneys out there ready to sue you if you give tPA and it goes bad, and to sue you if you do not give tPA. High stakes and no win for the ER doc!

Families want to do something when their loved one is having a stroke. If they have heard about tPA, they often come in with the expectation that it will be used, or at least a bias towards "doing something." Teling them that either there is nothing that can be done, or that there is an option but you can't wholly endorse it can evoke an angry or negative response from the family. In this litigous environment, the emotional factor only adds risk, regardless of the ultimate decision.

So it's a little frustrating to see that the cohort of patient with whom I am going to have this converstation may be getting a lot bigger. While I haven't gotten deeply into the data, on quick review, it seemed like delayed tPA didn't seem to offer much in the way of improved outcomes, and there was no rush to revise the current standards, which is good. I'll be watching to see if there is more movement towards relaxing the criteria.


  1. I want tPa...and a kitten.

    Anything less and I'll trash your Press-Ganey's

  2. I haven't been able to review the full study yet either but it appears most people were treated within 15 minutes after the 3 hr window. If the window is to be expanded the use of intracranial TPA is something that can be reviewed.

  3. We solve the issue for the ER docs at my home institution by having a neuro consult team specifically for "brain attacks." If an ER doc sees someone he/she thinks is a tPA candidate, they call the BAT and they decide if tPA is indicated, not the ER doc. So at least the ER doc doesn't have to worry about law suits because it isn't their call.

    Also, this allows the neurologists to go around humming the "batman" theme song.


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