An update on thrombolysis

perfusion mapDespite the recent upheaval in the emergency medicine community about the ACEP tPA-for-stroke guidelines, thrombolysis is one of the two foundations of modern stroke medicine. In a local stroke symposium, I gave a talk about new developments and folklore in tpa-ology. It also exposes our Augsburg data on thrombolysis with bleeding rate and all you could wish in a real life tpa setting. The talk introduced a new acronym for remembering the various causes of tpa-related ICH (I love acronyms). It reads CORTEX

  • C erebral amyloid angiopathy (extraischemic ICH)
  • O ld stroke (old meaning > 6h)
  • R ecanalization (recanalized vessels to dead tissue)
  • T rauma (bleeding into contusions)
  • E ndocarditis (rare but sometimes fatal)
  • X – coagulation (think of factor X, anticoagulants, ASS and the like)

If you can read German, you might want to give the presentation a try – here is the prezi link.


The IST-3 trial

It is the biggest randomized thrombolysis trial for stroke ever and it answers a lot of questions, such as

  • Are we safe with our (quite liberal) indications for tpa in stroke? Is the 4.5h window safe? It is, even 6h would be safe.
  • Do elder patients profit? They do! And even more than the younger ones!

The IST-3 trial is methodologically very advanced, has provided an overview of its statistical evaluation in advance. And it is actually quite readable. So go ahead and view the publication and all slides on their homepage.

Added after the fact: since I am a tpa believer (having done at least 150 thrombolyses for stroke last year) I probably don’t question the statistics enough. Make sure, you don’t fall into any trap and give the tpa agnosticians a try –  such as EM ireland.