Stroke: thrombolytics decrease death and dependency.

Clinical bottom line (level 1a)

  1. Patients with acute ischaemic stroke who are given thrombolytic therapy are less likely to suffer death or dependency, than those given placebo.
Wardlaw et al: The Cochrane Library, Issue 2, Oxford: Update Software 1999; 4: -
Expires March 2003

The study

Systematic review of randomised controlled trials of
  • Patients: within 14 days of an acute ischaemic stroke
  • Intervention: thrombolytic drugs compared with placebo
  • Outcome: death or dependency
Articles found in ? language using Cochrane Stroke Group trials register, MEDLINE, EMBASE, the Ottawa Stroke Trials Registry, 1979 - 1999 (search terms: Cochrane standard approach - further details in text ) and searched reference lists of articles and Japanese and other journals. Contacted researchers in the field, attended conferences and pharmaceutical companies.

Selection criteria: as above
Appraisal criteria: detailed
Articles excluded if: premature termination of trial, stroke not confirmed with CT scan or data in several different publications.

Seventeen trials involving 5216 patients were included.
There was significant heterogeneity with regards to total death.

The evidence

Outcome Time to outcome CER OR
(95% CI)		 NNT
(95% CI)
death or dependency (all trials) months /
(59.7%)		 0.75
(0.63 to 0.88) 		22
(13 to 67)
death of any cause days /
(9.8%)		 1.85
(1.48 to 2.32) 		-14
(-10 to -25)

  • Heterogeneity could not be explained by type of thrombolytic used (streptokinase, urokinase or rt-PA)
  • A subgroup analysis by time of presentation (within 3 hours) demonstrated an even greater improvement in death&dependency. (This is an exploratory analysis.)
  • There was no great evidence of heterogeneity with stroke severity at the time treatment was given.

Citation

  1. Wardlaw JM, Yamaguchi T, del Zappo G: Thrombolysis for acute ischaemic stroke. The Cochrane Library, Issue 2, Oxford: Update Software 1999; 4: -
Contributor: Clare Wotton and Bob Phillips, December 1999
Reviewer:

Clinical Question.
Patient acute ischaemic stroke
Intervention or Exposure thrombolytic drugs
Comparison placebo
Outcome death or dependency