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A Case-Control Study of Tissue Plasminogen Activator for Acute Ischemic Stroke

Published online by Cambridge University Press:  02 December 2014

J M Reid ,
S J Phillips ,
G J Gubitz ,
J Jarrett ,
C Christian  and
D Dai
J M Reid
Affiliation:
Institute of Neurological Sciences, Glasgow, Scotland
S J Phillips
Affiliation:
Department of Community Health and Epidemiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
G J Gubitz
Affiliation:
Department of Community Health and Epidemiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
J Jarrett
Affiliation:
Department of Community Health and Epidemiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
C Christian
Affiliation:
Department of Community Health and Epidemiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
D Dai
Affiliation:
Department of Community Health and Epidemiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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Abstract

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Background:

Randomized trials demonstrate that intravenous tissue plasminogen activator (tPA) improves outcome in acute ischemic stroke (AIS). To assess translation of this efficacy into effectiveness in routine clinical practice we performed a case-control study of tPA treatment for AIS in a single hospital.

Methods:

151 tPA-treated AIS patients (1996-2005) were matched 1:1 with blinding to outcome to controls from a prospective registry based on age, gender, pre-stroke Oxford handicap scale (OHS), stroke severity, and subtype. The outcomes were in-hospital death, symptomatic intracranial hemorrhage (SICH), length-of-stay (LOS), discharge OHS and long-term survival.

Results:

In-hospital mortality (23% vs. 24%) or long-term survival (median follow-up of 2 years) was not different between cases and controls (p=0.83). SICH occurred in 7.8% (95% CI 4.2-13.5%) of tPA-treated patients. Median LOS was non-significantly shorter for cases (13 [7-29] vs. 16 [8-32] days, p=0.14) but significantly shorter in tPA-treated vs. non-treated women (14 [7-28] vs. 20 [11-34] days, p=0.04). At discharge 6.6% (95% CI 1.1-12.0%) more tPA-treated patients than controls had no disability (OHS ≤1, p=0.02). However, there was no difference in discharge independence rates or proportion discharged home.

Conclusion:

We demonstrate minor improvements in early recovery after stroke with tPA but the impact is less dramatic than that reported in randomized trials. This may relate to timing of treatment and the type of patients treated.

Résumé:

RÉSUMÉ:<span class='italic'><span class='bold'>Contexte</span></span>:

Des etudes cliniques randomisees ont demontre que l’activateur du plasminogene tissulaire (tPA) administre par voie intraveineuse ameliore l’issue dans l’accident vasculaire cerebral ischemique aigu (AVCIA). Nous avons effectue une etude cas-temoin chez des patients d’un hospital presentant un AVCIA afin d’evaluer si l’efficacite potentielle du traitement par le tPA se traduit par une efficacite reelle en pratique clinique.

<span class='italic'><span class='bold'>Méthodes</span></span>:

151 patients, ayant subi un AVCIA et ayant ete traites par tPA entre 1996 et 2005, ont ete apparies 1:1 quant a l’age, au sexe, au score pre-AVC a l’Oxford Handicap Scale (OHS), a la severite de l’AVC et au sous-type, et en aveugle quant a l’issue, a des temoins tires d’un registre prospectif. Les criteres d’evaluation etaient le deces pendant l’hospitalisation, l’hemorragie intracranienne symptomatique (HICS), la duree du sejour hospitalier (DSH), le score OHS au moment du conge et la survie a long terme.

<span class='italic'><span class='bold'>Résultats</span></span>:

Nous n’avons constaté aucune différence entre les cas et les témoins (p = 0,83) quant a la mortalite intra-hospitaliere (23% vs 24%) et a la survie a long terme (suivi median de 2 ans). 7,8% des patients traites par le tPA ont presente une HICS (IC de 95% : 4,2 a 13,5%). La DSH mediane des cas etait plus courte (13 [7-29] vs 16 [8-32] jours, p = 0,14) mais la difference n’etait pas significative. Cependant elle etait significative pour les femmes traitees par le tPA par rapport a celles qui n’avaient pas recu ce traitement (14 [7-28] vs 20 [11-34] jours, p = 0,04). Au moment du conge hospitalier, les patients traités par le tPA qui n’avaient aucune invalidite etaient de 6,6% plus nombreux (IC de 95% : 1,1 a 12,0%) que les témoins (OHS ≤ 1, p = 0,02). Cependant, il n’y avait pas de différence quant au taux d’independence au moment du congé hospitalier ou quant á la proportion des patients qui retournaient á domicile.

<span class='italic'><span class='bold'>Conclusion</span></span>:

Nous démontrons qu’il existe une amélioration mineure quant à la recuperation precoce après un AVCIA si on administre du tPA, mais l’impact est moins dramatique que celui qui a été rapporte dans les études randomisées. Ceci pourrait ätre dû au moment où le traitement est administré et au type de patients traités.

Type
Original Articles
Information
Canadian Journal of Neurological Sciences , Volume 34 , Issue 4 , November 2007 , pp. 411 - 416
Copyright
Copyright © The Canadian Journal of Neurological 2007

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