Tissue Plasminogen Activator for Acute Ischemic Stroke

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Abstract
In “Tissue Plasminogen Activator [t-PA] for Acute Ischemic Stroke” (Dec. 14 issue),1 it is reported that treatment with t-PA increases a patient's chance of recovering from an ischemic stroke without any, or only minimal, disability or neurologic deficit. Despite this optimistic conclusion, several methodologic issues and the demonstrated risks of treatment with t-PA suggest a more cautious interpretation. Although the study was randomized, there were important base-line differences that favored the t-PA–treated patients. Overall, more patients in the t-PA–treated group than in the placebo group had been receiving aspirin before the event (odds ratio, 1.697; 95 percent confidence interval, 1.199 to 2.404; P = 0.002). This difference may have been more important than suggested by post hoc analysis, since some of the patients may have actually had a transient ischemic attack — for which aspirin is known to be beneficial — rather than a completed stroke. The importance of this possible pretreatment advantage may have been enhanced by the protocol, which precluded the use of aspirin or other antithrombotic therapy during the early phase of treatment. By contrast, the aspirin-like actions of t-PA would have been helpful to such patients.2