Intravenous TPA for Ischemic Stroke Patients: Houston Experience 1996–2000
Background: Implementation of intravenous (IV) tissue plasminogen activator (TPA) therapy with the NINDS protocol has been reported with variable safety. Our center has an experienced stroke team of fellows and stroke faculty servicing one University hospital and three community hospitals. Methods: We report our experience in the treatment of 269 consecutive patients with ischemic stroke within the first 3 hours after symptom onset with 0.9 mg/kg IV TPA according to the NINDS protocol. Results: A total of 269 patients were treated between 1/96 and 6/00: median age 69 (range 24–93 years, females 48%). Pre-treatment NIHSS was 14±6 (median 14, range 4–33 points). TPA bolus was given at 137 min (range 30–180 minutes) with 28% of patients treated within 2 hours. Median door-to-needle time was 68 minutes (range 10–129 minutes). Overall symptomatic ICH rate was 4.5% (range 2.6% - 8.7% between hospitals, ns), with a decline noted from 1996 to 2000 (Table). Protocol violations (excessive blood pressure, seizure at onset) were found in 13% of all patients and symptomatic ICH rate in these patients was 15%. At 24 hours NIHSS score was 9±8 (median 8, range 0–36 points). In hospital mortality was 15% and discharge NIHSS score was 6±7 (median 3, range 0–36). Long-term follow-up will be reported. Conclusions: Intravenous TPA in a dose of 0.9 mg/kg can be given with a risk of symptomatic ICH lower than previously reported. Safety of TPA improved from 1996 to 2000. We conclude that the safety of TPA therapy depends more on the expertise of the treating team than the type of the hospital.