We all have our anecdotal stories from academic medical centers staffed by stroke neurologists, cases in which they have called for thrombolytic therapy in acute ischemic stroke for profoundly inappropriate candidates. Hearing such sad tales, one hopes such rogue uses of lytics are the lunatic fringe, isolated cases of madness and zealotry.
But, no.
This survey of general and vascular neurologists at two academic institutions in New York demonstrates such aggressive use of tPA for stroke is the pervasive norm, rather than an isolated occurrence. These authors provided 40 clinicians with a survey consisting of 110 case scenarios of patients presenting with symptoms of acute stroke. These case scenarios were further stratified by NIHSS, with 22 cases each of NIHSS 1 through 5. Of the 17 clinicians responding, it was almost unanimous they would use tPA for all cases of NIHSS 3, 4, and 5. Neurologists would use lytics 57% of the time at NIHSS 2, and 37% of the time with NIHSS 1.
Now, the NIHSS is non-linear, and significant disability can be present at NIHSS 1 and 2 – but even remotely considering lysis at NIHSS 1 or 2 should be the exception rather than an almost balanced split. In a world where the new ACEP Clinical Policy draft is rolling back its level of recommendation for tPA, it is simply boggling to see how the other half thinks – that no frontier is too formidable for tPA.
“To Treat or Not to Treat? Pilot Survey for Minor and Rapidly Improving Stroke”
http://www.ncbi.nlm.nih.gov/pubmed/25604250