More on the use of TPA in Stroke

Note*** This article is a response to a previous article of a few days ago, entitled So You Think You Are Having a Stroke.---------------------------------------   As an emergency physician of 34 years, the last 5 at a stroke center that treated more than 4 strokes a day, I was very interested in the thoughts about TPA.  I was especially gratified to hear of the author’s husband’s good outcome since stroke is and continues to be a devastating event for most patients.  She also does a tremendous service making people aware of the symptoms.Like most medicines TPA, which dissolves blood clots, is a double-edged sword:  near miraculous when used correctly, catastrophic when not.My purpose in writing is not to argue for or against recommending San Fernando Clinic stocking the drug.  I want to give the reader the information necessary to make an informed decision which is a guiding principle of my blog, thetruthaboutmedicine.com.The following is a “Cliff Notes” summary of the major points.  For anyone interested in delving deeper, please e-mail me at rtfitz10@gmail.com.

THE HISTORY OF TPA IN STROKES:

TPA is a drug that breaks the bonds holding a blood clot together (hence the moniker “clot-buster”) and is useful in ischemic strokes where the underlying cause is a clot plugging a blood vessel in the brain.  When given intravenously, it dissolves all clots even those outside the brain.

About 12 years ago there was a landmark study purportedly showing a statistical benefit to using TPA in stroke.  This created a lot of enthusiasm because up to then there was no effective acute treatment.  But you should know this about the study:

•  There were only 600 patients in the study (300 treated - 300 placebo) compared with literally 100,000’s in studies leading to the use of TPA in heart attacks.

•  The study showed no immediate benefit to treated patients.  A statistical improvement was only seen 90 days after the stroke.

•  Treated patients had a 7-fold increase in intracranial hemorrhage.

•  Shortly (in medical terms) after this single study the American Heart Association declared TPA “the standard of care” guaranteeing the original study would never be repeated or validated.

There is still some skepticism in the medical community about its use; but in fairness, most neurologists recommend it if used correctly.

TPA IS NOT A BENIGN DRUG:

In our stroke center TPA is only given under a strict protocol.  Here are some of the elements:

•      Paramedics - Start IV, check blood pressure and heart rhythm, check blood sugar, attempt to get accurate history from family and patient as to onset of symptoms, and make radio contact with the E.D. so the entire stroke team can be alerted.

•      In the E.D. we follow a 22-page protocol that has strict inclusion/exclusion criteria, mandated blood work and EKG’s, a 22-element neurologic exam to elicit a stroke score, a blood pressure control protocol if needed using intravenous medications, immediate CAT scan read by a radiologist trained in neuroradiology, mandatory consultation with a neurologist (who comes to the E.D. to see the patient except in the middle of the night).  The neurological exam is repeated every 15 minutes and if the patient meets all inclusion/exclusion criteria, and if the blood pressure is controlled, and if the CAT scan excludes hemorrhage, and if it has been less than 3 hours since the onset of symptoms, then, and only then, the neurologist at the bedside makes the decision to give TPA.  Our institution had a neurosurgeon on standby in the event TPA caused a cerebral hemorrhage that required surgical intervention.

The point is:  TPA should only be used by a system organized to give it safely and appropriately.


IRISH WHISKEY:

While I’ll let the reader make up their own mind about TPA in stroke, I must comment about caffeinol.  I suspect the comments in the original article were tongue in cheek and I know this will cause my ancestors to roll over in their graves, but please don’t consider Irish whiskey as an adjunct to conventional therapy because:

1.    Caffeinol has only been studied in rats and only given intravenously and not by mouth.  There are no human studies.  The caffeine and alcohol raise blood pressure which complicates subsequent treatment.

2.    The risk of aspiration (swallowing liquid into the lungs) is extremely high in acute stroke, and why complicate a serious situation?

Hopefully this discussion will cause awareness of stroke and stimulate efforts to address health issues of ex-Pats in the area.