Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials
Journal Club Summary
Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, Albers GW, Kaste M, Marler JR, Hamilton SA, Tilley BC, Davis SM, Donnan GA, Hacke W; ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group, Allen K, Mau J, Meier D, del Zoppo G, De Silva DA, Butcher KS, Parsons MW, Barber PA, Levi C, Bladin C, Byrnes G.
Lancet. 2010 May 15;375(9727):1695-703
This pooled analysis of 8 large double-blind randomized controlled trials of IV t-PA in acute stroke found that there is increased odds of a significant benefit with regard to 3-month functional outcome in acute stroke patients if treated with t-PA within 4.5 hours of stroke onset. Serious hemorrhage rates were found to be independent of onset to treatment time (OTT), however mortality increased as the OTT increased, most notably after 4.5 hours. The group recognized this study, and in particular the trial ECASS III, as a practice-changer, which led to the Canadian stroke guidelines expansion of the thrombolytic treatment window from 3 to 4.5 hrs. Although viewed as a high quality analysis, there was some question as to the methodology and appropriateness of pooling the data of these trials as the homogeneity of the studies was not described or objectively assessed in the paper.
By Dr. Rachel DeLong