Stroke Treatment With Intravenous Tissue-Type Plasminogen Activator

n this edition of Circulation, Kim and colleagues 1 present data from the Get With The Guidelines-Stroke (GWTG-S) registry, with a focus on correlating time to treatment with intravenous tissue-type plasminogen activator (tPA; alteplase) and hospital discharge outcomes.The take-home message is that the sooner a patient is treated with intravenous tPA, the better the odds of having a favorable outcome.This was especially true for the small minority of patients (1.3%) who received intravenous tPA within 60 minutes of stroke onset.Although intravenous tPA has a treatment window of 4.5 hours (from symptom onset or last known time well to initiation of therapy), only 1.3% of patients began therapy within 60 minutes of stroke onset. 1 However, patients receiving therapy within 60 minutes of symptom onset had a 22% to 25% relative increase in being discharged home or being ambulatory at the time of hospital discharge compared with patients who received intravenous tPA beyond 60 minutes.Patient outcomes worsened as the onset-to-treatment time increased.This is not a novel finding; prior studies have found similar correlations.2 Some of this degradation in benefit from tPA followed a linear pattern, whereas at other times the pattern was nonlinear, with a steeper graded association between longer onset-to-treatment time and worse outcomes noted in the first 3 hours after symptom onset There are several other important findings from this study.Intravenous tPA for stroke has been a US Food and Drug Administration-approved medical therapy for ≈20 years, yet it remains grossly underused.In the Kim et al 1 report, only 65 000 of ischemic stroke patients (6.1%) were treated with intravenous alteplase.Although some patients were likely excluded for valid medical reasons (anticoagulant use, exceedingly high blood pressures, recent surgery, or hemorrhage), it is likely that many were not eligible for treatment because of delayed presentation times and hospital delays in diagnosis and treatment.The low use of intravenous tPA is even more problematic when considering the lack of alternative medical therapies for acute ischemic stroke.Endovascular therapy is now an option for those patients with large-vessel occlusions; however, this approach is available at only select medical centers.3 Despite ongoing concerns about the safety of intravenous tPA for stroke, data from the GWTG-S study are reassuring.The overall rate of symptomatic intracerebral hemorrhage reported was 4.4%, which is ≈2% lower than reported in the pivotal National Institute of Neurological Disorders and Stroke tPA study published in 1995. 4 These findings further support the relative safety of intravenous tPA in routine clinical use.The rate of serious systemic bleeding was only 1%.The rates of these bleeding events were reduced in patients treated sooner compared with later. 1 Patients were enrolled from 1456 hospital sites, which represents ≈25% of all acute care hospitals in the United States.The average hospital size was ≈400 beds, Stroke Treatment With Intravenous Tissue-Type Plasminogen Activator More Proof That Time Is Brain