On the Shoulders of Giants
I still want to believe...
ECASS III was a large RCT of patients with acute ischemic stroke presenting 3-4.5 hours from the time of onset. Similar to NINDS, more had a favorable outcome with alteplase than placebo, NNT = 14. But more also had symptomatic intracranial hemorrhage, NNH = 45 (NNH = 23 by the NINDS definition).
The window for tPA got wider with this study; ECASS III expanded the time of administration to 4.5 hours. But earlier is still better when it comes to stroke treatment.
Here are some great FOAMed resources on tPA in stroke.
- We covered the NINDS trial on EM Topics.
- Core EM has a very skeptical, overview of NINDS worth reading, with links to additional FOAMed resources - highly recommended.
- REBEL EM has an incredible compendium of stroke research.
- Finally, Drs. Jagoda and Swaminathan have a tPA debate on EMCrit.
Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke.
N Engl J Med. 2008 Sep 25;359(13):1317-29. doi:10.1056/NEJMoa0804656.