Strokes and tPA, it depends how you read the evidence. The NINDS trial showed a improved outcome with the use tPA, but can be critisised for a number of things. The two new trials in JAMA this week were attempts to validate the NINDS trial findings. The STARS trial (sponsored by the makers of tPA) showed improved outcomes and supported the use of tPA, within clearly defined circumstances, while the community hospital study showed worse outcomes ( but can be faulted for low numbers of patients being thrombolysised and for about 50% protocol violation). Ive spent alot of time reading and re-reading these and the other non-favourable trials and have decided if it was my CVA and I met the NINDS trial criteria I would want to receive tPA - so I surpose thats a good starting point for deciding if thromboylsis is appropriate for my patients. But I think like anything the patient and their family need to be actively involved in the decision. As for the resource issue, only a small number of patients will be eligible for thrombolysis so that cost will be minimal. The real cost will be in CTing stroke patients - but the NINDS criteria excludes large numbers before you even get to scanning so again the numbers woundnt be that large. Now lets start talking about routinely CT minor head injuires and doing away with skull films all together and see if we can really spend some of the NHS's money.
Craig
Dr Craig Ellis
Registrar in Emergency Medicine
Wellington Hospital
Wellington, New Zealand
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