Hostname: page-component-586b7cd67f-r5fsc Total loading time: 0 Render date: 2024-12-06T05:46:04.148Z Has data issue: false hasContentIssue false
  • English
  • Français

tPA use for Stroke in the Registry of the Canadian Stroke Network

Published online by Cambridge University Press:  02 December 2014

Janel O. Nadeau ,
Steven Shi ,
Jiming Fang ,
Moira K. Kapral ,
Janice A. Richards ,
Frank L. Silver ,
Michael D. Hill  and
on behalf of the investigators for the Registry of the Canadian Stroke Network
Janel O. Nadeau
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Steven Shi
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Jiming Fang
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Moira K. Kapral
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Janice A. Richards
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Frank L. Silver
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Michael D. Hill*
Affiliation:
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
*
Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Foothills Hospital, Rm 1242A, 1403 29th Street NW, Calgary, Alberta, Canada T2N 2T9
Rights & Permissions [Opens in a new window]

Abstract:

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Background:

Thrombolytic therapy with recombinant tissue plasminogen activator (tPA) has been shown to be cost-effective and safe. Thrombolysis for stroke with tPA is now a standard of care in North America. However, it is only used on a small percentage of patients.

Methods:

The Registry of the Canadian Stroke Network was a consent-based stroke registry from 21 hospital sites across Canada. Using the thrombolysis data in phase 1 and 2 of the Registry, we sought to describe the use of stroke thrombolysis and its outcomes.

Results:

A total of 4107 patients were diagnosed with ischemic stroke in phase 1 and 2 of the Registry, of which 8.9% were treated with tPA. In consented tPA patients, the method of tPA administration was 85.8% IV only, 9.0% IA only, and 5.2% IV/IA combined. Patients had a median onset-to-treatment time of 167 minutes [IQR 140-188]. One quarter (25.5%) of eligible candidates (time from onset <150 minutes) were treated with tPA. Protocol violations occurred in 27.7% (67/242) of patients with 14.9% (10/67) mortality. Overall, in-hospital mortality was 11.6%. Lower Canadian Neurological Scale score and higher glucose level were predictive of mortality The symptomatic intracerebral hemorrhage (ICH) rate (phase 2 only) was 4.3%. The mean Stroke Impact Scale-16 score at six months was 73.2, approximately equivalent to a modified Rankin scale score of 2.

Conclusions:

At selected hospitals in Canada, thrombolysis use is higher than previously reported rates. Thrombolysis continues to be safe and effective in Canada.

Résumé:

RÉSUMÉ: Contexte:

La démonstration est faite que la thrombolyse au moyen de l’activateur du plasmagène tissulaire recombinant (rtPA) est rentable et sûre. La thrombolyse par le tPA pour traiter l’accident vasculaire cérébral (AVC) fait maintenant partie du traitement standard en Amérique du Nord. Cependant ce traitement n’est administré qu’à un petit nombre de patients.

Méthodes:

Le registre du Réseau canadien contre les accidents cérébro-vasculaires est un registre avec consentement de patients provenant de 21 hôpitaux canadiens. Au moyen des données sur la thrombolyse pendant les phases 1 et 2 du registre, nous décrivons l’utilisation de la thrombolyse dans l’AVC ainsi que les résultats de ce traitement.

Résultats:

4107 patients ont reçu un diagnostic d’AVC ischémique pendant les phases 1 et 2 du registre, dont 8,9% ont été traités par le rtPA. Parmi les patients qui ont donné leur consentement, le mode d’administration du rtPA était par voie IV seule chez 85,8%, par voie IA seule chez 9,0% et par voie IV et IA combinées chez 5,2%. Le délai médian entre le début de l’AVC et le traitement était de 167 minutes (intervalle interquartile de 140 à 188 minutes). Le quart des patients éligibles (25,5%), c’est à dire ceux chez qui moins de 150 minutes s’étaient écoulées depuis le début de l’AVC ont reçu du rtPA. Des dérogations au protocole sont survenues chez 27,7% des patients (67/242) avec une mortalité de 14,9% (10/67). Au total, la mortalité hospitalière était de 11,6%. Un score plus bas à l’Échelle neurologique canadienne et un taux plus élevé de glucose étaient les deux marqueurs prédisant la mortalité. Le taux hémorragie intracérébrale symptomatique était de 4,3% (phase 2 seulement). Le score moyen au stroke impact Scale-16 six mois plus tard était de 73,2, ce qui est à peu près équivalent à un score de 2 à l’échelle modifiée de Rankin.

Conclusions:

Le taux de thrombolyse est plus élevé que rapporté antérieurement dans certains centres hospitaliers canadiens. La thrombolyse demeure un traitement sûr et efficace au Canada.

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 32 , Issue 4 , November 2005 , pp. 433 - 439
Copyright
Copyright © The Canadian Journal of Neurological 2005

References

1. Canadian Stroke Network Website. http://www.canadianstrokenetwork.ca/aboutus/stroke101.php. Accessed January 19, 2005.Google Scholar
2. NINDS tPA Stroke Study Group. Tissue Plasminogen Activator forAcute Ischemic Stroke. New Eng J Med 1995;333:1581–1588.Google Scholar
3. Steiner, T, Bluhmki, E, Kaste, M, et al. (ECASS Study Group). TheECASS 3-hour cohort: Secondary analysis of ECASS data by time stratification. European Cooperative Acute Stroke Study. Cerebrovasc Dis 1998;8:198–203.Google Scholar
4. Hacke, W, Kaste, M, Fieschi, C, et al. Randomised double-blindplacebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998;352:1245–1251.CrossRefGoogle Scholar
5. Chiu, D, Krieger, D, Villar-Cordova, C, et al. Intravenous tissueplasminogen activator for acute ischemic stroke: feasibility, safety, and efficacy in the first year of clinical practice. Stroke 1998;29:18–22.Google Scholar
6. Graham, GD. Tissue plasminogen activator for acute ischemic strokein clinical practice: a meta-analysis of safety data. Stroke 2003;34:2847–2850.Google Scholar
7. Chapman, KM, Woolfenden, AR, Graeb, D, et al. Intravenous tissueplasminogen activator for acute ischemic stroke: A Canadian hospital's experience. Stroke 2000;31:2920–2924.Google Scholar
8. Buchan, AM, Barber, PA, Newcommon, N, et al. Effectiveness of t-PA in acute ischemic stroke: outcome relates to appropriateness. Neurology 2000;54:679–684.Google Scholar
9. Sinclair, SE, Frighetto, L, Loewen, PS, et al. Cost-Utility analysis oftissue plasminogen activator therapy for acute ischaemic stroke: a Canadian healthcare perspective. Pharmacoeconomics 2001;19:927–936.Google Scholar
10. Health Canada. Alteplase (Activase ® rt-PA) for acute ischemicstroke: special precautions for new indication. Canadian Adverse Reaction Newsletter 1999;9:1–3.Google Scholar
11. Albers, GW, Bates, VE, Clark, WM, et al. Intravenous tissue-typeplasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA 2000;283:1145–1150.Google Scholar
12. Hill, MD, Buchan, AM and the CASES Investigators. Methodologyfor the Canadian Activase for Stroke Effectiveness Study (CASES). Can J Neurol Sci 2001;28:232–238.CrossRefGoogle Scholar
13. CASES Investigators. TheCanadian Alteplase for Stroke Effectiveness Study (CASES). CMAJ 2005; (in press).Google Scholar
14. Hill, MD, Barber, PA, Demchuk, AM, et al. Building a “brain attack” team to administer thrombolytic therapy for acute ischemic stroke. CMAJ 2000;162:1589–1593.Google Scholar
15. Barber, PA, Zhang, J, Demchuk, AM, Hill, MD, Buchan, AM. Why arestroke patients excluded from TPA therapy? An analysis ofpatient eligibility. Neurology 2001;56:1015–1020.Google Scholar
16. Wang, DZ, Rose, JA, Honings, DS, Garwacki, DJ, Milbrandt, JC. Treating acute stroke patients with intravenous tPA. The OSF stroke network experience. Stroke 2000;31:77–81.Google Scholar
17. Kothari, R, Sauerbeck, L, Jauch, E, et al. Patients' Awareness ofStroke Signs, Symptoms, and Risk Factors. Stroke 1997;28:1871–1875.CrossRefGoogle Scholar
18. Pancioli, AM, Broderick, J, Kothari, R, et al. Public perception ofstroke warning signs and knowledge of potential risk factors. JAMA 1998;279:1288–1292.Google Scholar
19. Ovbiagele, B, Saver, JL, Fredieu, A, et al. PROTECT: a coordinatedstroke treatment program to prevent recurrent thromboembolicevents. Neurology 2004;63:1217–1222.Google Scholar
20. United States Department of Health and Human Services. HealthyPeople 2010: Volume I (second edition) — Objectives for Improving Health, Focus Area 12. http://www.healthypeople.gov/Document/HTML/Volume1/12Heart.htm. AccessedDecember 7, 2004.Google Scholar
21. Katzan, IL, Furlan, AJ, Lloyd, LE, et al. Use of tissue-typeplasminogen activator for acute ischemic stroke: the Clevelandarea experience. JAMA 2000;283:1151–1158.Google Scholar
22. Bravata, DM, Kim, N, Concato, J, Krumholz, HM, Brass, LM. Thrombolysis for acute stroke in routine clinical practice. Arch Intern Med 2002;162:1994–2001.CrossRefGoogle ScholarPubMed
23. Katzan, IL, Hammer, MD, Hixson, ED, et al. Cleveland Clinic HealthSystem Stroke Quality Improvement Team. Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Arch Neurol 2004;61:346–350.Google Scholar
24. Kapral, MK, Laupacis, A, Phillips, SJ, et al. Investigators of theRegistry of the Canadian Stroke Network. Stroke care delivery in institutions participating in the Registry of the Canadian Stroke Network. Stroke 2004;35:1756–1762.Google Scholar
25. Tu, JV, Willison, DJ, Silver, FL, et al, for the Investigators in theRegistry of the Canadian Stroke Network. Impracticability of Informed Consent in the Registry of the Canadian Stroke Network. N Engl J Med 2004;350:1414–1421.CrossRefGoogle ScholarPubMed
26. Duncan, PW, Lai, SM, Bode, RK, Perera, S, De Rosa, J. Stroke ImpactScale-16: A brief assessment of physical function. Neurology 2003;60:291–296.Google Scholar
27. Edwards, B, O’Connell, B. Internal consistency and validity of theStroke Impact Scale 2.0 (SIS 2.0) and SIS-16 in an Australian sample. Qual Life Res 2003;12:1127–1135.CrossRefGoogle Scholar
28. Grau, AJ, Weimar, C, Buggle, F, et al. Risk factors, outcome, andtreatment in subtypes of ischemic stroke: the German stroke data bank. Stroke 2001;32:2559–2566.Google Scholar
29. O’Connor, RE, McGraw, P, Edelsohn, L. Thrombolytic therapy foracute ischemic stroke: why the majority of patients remain ineligible for treatment. Ann Emerg Med 1999;33:9–14.Google Scholar
30. Furlan, A, Higashida, R, Wechsler, L, et al. Intra-arterial prourokinasefor acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999;282:2003–2011.Google Scholar
31. IMS Study Investigators. Combined intravenous and intra-arterialrecanalization for acute ischemic stroke: the InterventionalManagement of Stroke Study. Stroke 2004;35:904–911.Google Scholar
32. Lewandowski, CA, Frankel, M, Tomsick, TA, et al. Combinedintravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke(EMS) Bridging Trial. Stroke 1999;30:2598–2605.CrossRefGoogle ScholarPubMed
33. Marler, JR, Jones, PW, Emr, P, (Eds). The National Institute ofNeurological Disorders and Stroke. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. National Institutes of Health. Bethesda, Maryland. August 1997.Google Scholar
34. Roquer, J, Campello, AR, Gomis, M. Sex differences in first-everacute stroke. Stroke 2003;34:1581–1585.CrossRefGoogle ScholarPubMed
35. Arboix, A, Oliveres, M, Garcia-Eroles, L, et al. Acute cerebrovasculardisease in women. Eur Neurol 2001;45:199–205.CrossRefGoogle Scholar
36. Ayala, C, Croft, JB, Greenlund, KJ, et al. Sex differences in USmortality rates for stroke and stroke subtypes by race/ethnicity and age, 1995 to 1998. Stroke 2002;33:1197–1201.Google Scholar
37. Wyller, TB, Sodring, KM, Sveen, U, Ljunggren, AE, Bautz-Holter, E. Are there gender differences in functional outcome after stroke? Clin Rehabil 1997;11:171–179.Google Scholar
38. Kent, DM, Price, LL, Ringleb, P, Hill, MD, Selker, HP. Sex-baseddifferences in response to recombinant tissue plasminogen activator in acute ischemic stroke: a pooled analysis of randomized clinical trials. Stroke 2005;36:62–65.Google Scholar