Therapy

Thrombolysis is applicable for patients who understand the risks ^d and

• present within 3 to 6 hours of symptom-onset ^c with a clear neurological deficit ^d
• have a CT scan which excludes a haemorrhagic stroke ^a
• have neurological deficit that is neither very mild or very severe ^d
• have no recent trauma or surgery, ^d or no active peptic ulcer disease ^d

Why?

• Thrombolysis reduces dependency at 3 months ^a but not clearly at 1 year. ^d
• Patients given thrombolysis are more likely to die, particularly early and from intracranial haemorrhage. ^a
• No thrombolytic agent or dose has been shown to be clearly better than another. ^d
• Neurologists and radiologists only correctly interpret 83% of CT scans (95% CI: 65% to 100%) and emergency physicians only 67% of scans (95% CI: 43% to 91%) for eligibility for thrombolysis. ^c

Thrombolysis kills more patients, but reduces dependency in those that survive.

Patient	Treatment	Comparison	Outcome	CER	OR (95% CI)	NNT (95% CI)
acute ischaemic stroke a	thrombolysis	placebo	death at 7-10 days	10%	1.85 (1.48 to 2.32)	-14 (-25 to -10)
			fatal intracranial haemorrhage at 7-10 days	1.0%	4.15 (2.96 to 5.84)	-32 (-51 to -21)
			any intracranial haemorrhage at 7-10 days	2.5%	3.53 (2.79 to 4.45)	-17 (-24 to -13)
			death at 1-3 months	16%	1.21 (1.13 to 1.52)	-37 (-59 to -16)
			death or dependency at 1-3 months	59%	0.83 (0.73 to 0.94)	22 (13 to 67)

Alteplase reduces dependency

Patient	Treatment	Comparison	Outcome	CER	OR (95% CI)	NNT (95% CI)
acute ischaemic stroke a	alteplase	placebo	independence at 3 months	46%	-8.2 (-15 to -1.3)	12 (7 to 75)