Current Advances in Emergency Department Care of Acute Ischemic Stroke - EXTRA Supplement -

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Publication Date: June 2019 (Volume 21, Supplement 6)

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Editor-in-Chief

Introduction

Stroke is the fifth leading cause of death in the United States and an important cause of long-term disability.1 Approximately 795,000 people suffer from stroke each year (610,000 primary strokes and 185,000 recurrent strokes),1 with ischemic stroke representing the vast majority of all stroke types (87%).2 The cornerstone of acute ischemic stroke treatment relies on rapid clearance of an offending thrombus in the cerebrovascular system.3 Advanced neuroimaging and clinical trials, together with continuous adjustments of inclusion/exclusion criteria, have helped emergency clinicians to rapidly and more accurately identify the patients who will benefit from acute stroke treatment.

Excerpt From This Issue

Alteplase (recombinant tissue plasminogen activator [rt-PA]) was the first drug approved by the United States Food and Drug Administration (FDA) for treatment of acute ischemic stroke. rt-PA is a protease derived by recombinant DNA technology that activates fibrin-bound plasminogen, leading to plasmin formation and the disintegration of fibrin clots.^4,5 In 1995, the National Institute of Neurological Disorders and Stroke (NINDS) Recombinant Tissue Plasminogen Activator trial showed that patients suffering from ischemic stroke who received intravenous (IV) rt-PA in a dose of 0.9 mg/kg within 3 hours of symptom onset had a more favorable outcome at 3 months than those who received placebo (odds ratio [OR] 1.7; 95% confidence interval [CI], 1.2 to 2.6; P = .008).⁶ Since then, other studies and randomized controlled trials have confirmed the safety and efficacy of IV thrombolysis (IVT).^7-12

In 2008, the ECASS III study¹³ showed a statistically significant benefit in selected patients treated with IV rt-PA between 3 hours and 4.5 hours from symptom onset. Additional studies have supported the use of IVT in a time window as late as 4.5 hours after symptom onset.^14-16 The IST-3 trial attempted to extend the time window for IVT administration beyond the 4.5-hour time window, but was unable to show a meaningful improvement in outcome beyond that time point.¹⁷ However, the recently published EXTEND trial reveals promising results for extending the time window up to 9 hours, in selected populations.¹⁸ The benefit of IVT in favorable neurologic outcome has been demonstrated to persist at both 3 and 12 months after stroke occurrence.^6,19