You Can’t Spell “Insanity” Without tPA

When you think you’ve seen it all – a call to administer tPA to acute stroke patients without a prior non-contrast CT.

Indeed, in this “Views & Reviews” article, the authors ask explicitly the question: “Is the administration of alteplase to patients with primary ICH that harmful?”  After much stimulating confabulation, the authors bafflingly conclude: “we cannot argue with confidence that alteplase administration to patients with ICH is harmful”.

Perhaps they’ve never treated patients with alteplase personally, and they further mis-cite or misinterpret the evidence regarding the influence of cerebral microbleeds on symptomatic intracranial hemorrhage.  Despite the clear evidence from multiple meta-analyses that cerebral microbleed burden prior to alteplase administration leads to substantially increased risk of ICH and neurologic worsening, these authors sum up this evidence as “either no increased risk of symptomatic ICH or an increased risk that does not necessarily preclude an overall benefit from alteplase.”

Nonsense.

Even better, the entire purpose of their intellectual exercise boils down to discarding the inconvenience of pre-lytic CT so that alteplase can be delivered pre-hospital.  Yes, rather than clinically correlating the presentation with maximal vascular and perfusion information to consider the safest, most potentially effective (if any) reperfusion therapy – these authors are promoting administration of a $6000 medication in a pre-hospital setting with a paucity of diagnostic expertise or technology available.

Good plan.

“And why not thrombolysis in the ambulance (at least for some)?”
http://www.neurology.org/content/early/2016/06/15/WNL.0000000000002835.short

5 thoughts on “You Can’t Spell “Insanity” Without tPA”

  1. If it doesn't cause bleeding OUTSIDE of the vascular system, then we shouldn't expect it to cause bleeding INSIDE of the system (i.e. revascularization).

  2. If I have a stroke on duty and I can't kick the syringe out of the resident's hand, just give me the tPA, then do the CT. If it shows blood, give me another dose of tPA.

  3. Perhaps you never read a pre-tPA NCCT personally, otherwise you would have known that cerebral microbleeds cannot be diagnosed by NCCT (only by MRI), so your point is nonsensical: NCCT makes no difference as regards the detection of cerebral microbleeds.

    1. Ah – I’m not advocating for using the NCCT to rule-out CMB; in this article, the authors discuss the relevance of CMB in predicting sICH, and I believe they are off target.

      This is the assertion with which I take issue:
      “Of note, recent studies of alteplase-associated symptomatic ICH in stroke patients with previous microbleeds, i.e., patients with compromised small vessels who had already experienced cerebral bleeding, found either no increased risk of symptomatic ICH or an increased risk that does not necessarily preclude an overall benefit from alteplase.
      To summarize, we cannot argue with confidence that alteplase administration to patients with ICH is harmful, neither can we say it is safe.”

      I believe the evidence is rather clear that CMB prognosticate a higher risk of sICH. These authors are trying to justify the potential safety of giving alteplase to ICH, which I find nonsensical.

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