Acute Stroke Treatments

In the acute setting, thrombolysis with TPA has been approved by the FDA for the treatment of ischemic stroke where the therapy can be instituted within 3 hours of symptoms. The NIH TPA trials demonstrated a consistent and persuasive improvement in 3-month outcome based on the NIH Stroke Severity Scale, Glasgow Outcome Score, Barthel Index of Activities of Daily Living and the Rankin Score (Global Test OR=l.7, p=0.008). The TPA was given at a dose of 0.9 mg per Kg for a maximum of 90 mg with 10% as a bolus and the remainder through a 1-hour IV infusion. There was an elevated risk of intracerebral hemorrhage or hemorrhagic infarction (symptomatic intracranial hemorrhage risk of 6% to 7%). There were numerous exclusion criteria including no evidence of any recent bleeding or chance of bleeding diathesis or uncontrolled hypertension. We must choose our patients accordingly when we consider the use of TPA.

Data from the International Stroke Trial and the Chinese Aspirin Stroke Trial have indicated that the use of aspirin acutely among patients treated within 48 hours will reduce stroke recurrence risks and mortality. The use of heparin is still controversial. Subcutaneous heparin at 12500 BID was found to increase the risk of hemorrhage, while 5000 BID seemed safe and offered some protection from early death, stroke recurrence, and PE. Recent results from the TOAST trial which compared low molecular weight heparinoid to placebo among patients with ischemic stroke treated within 24 hours were not significant except for the atherosclerotic subgroup. Further studies are being planned.

Numerous acute stroke trials are being conducted or have recently been completed with various neuroprotective agents such as Lubeluzole, Glycine antagonists and NMDA antagonists. The future seems promising that another agent will prove useful in reducing the mortality and morbidity from ischemic stroke.

Leave a Reply

Your email address will not be published. Required fields are marked *