Medico-Legal Aspects of Using Tissue Plasminogen Activator in Acute Ischemic Stroke

Bruce, Nhu; Neil, William P; Zivin, Justin A.

doi:10.1007/s11936-011-0122-0

Cited by 14 publications

(7 citation statements)

References 18 publications

(26 reference statements)

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“…Many subjectively felt that the benefit, if at all, with IVTT is modest and bleeding risk is high. [ 5 6 7 ] They do remember cases in which they landed in trouble. We thought that this feeling of the treating neurologists might be another reason for the low IVTT rates.…”

Section: Discussionmentioning

confidence: 99%

“…[ 2 3 ] Although the barriers for thrombolysis are many,[ 4 5 ] low acceptance among physicians may be an important factor. [ 6 ] Over-projected bleeding risk and subjective feel of futility[ 7 ] may be significant in this regard. [ 6 ] The clinical decision-making about IVTT varies among physicians.…”

Section: Introductionmentioning

confidence: 99%

“…[ 6 ] Over-projected bleeding risk and subjective feel of futility[ 7 ] may be significant in this regard. [ 6 ] The clinical decision-making about IVTT varies among physicians. [ 7 8 ] The negative role of previous bad patient outcome in subsequent decision-making is well established.…”

Section: Introductionmentioning

confidence: 99%

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Real-World Effectiveness of Intravenous Stroke Thrombolysis is more than the Expectation of Practicing Neurologists

Ghafoor

Khan

Shehna

2018

Journal of Neurosciences in Rural Practice

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Background:The objective of the study was to compare the actual results of intravenous thrombolytic therapy (IVTT) in acute ischemic stroke with results anticipated by neurologists in practice.Methods:Neurologists practicing in Thrissur metropolitan region, covering a population of 1.8 million, were telephonically surveyed about the number of yearly IVTT and their expert opinion/comment about effects of thrombolysis. This was compared with the results of IVTT from a single institution in the same region from 2012 to 2016.Results:Eight neurologists in the region give approximately 140–150 IVTT per year. Nearly 20%–40% (median 32%) patients have good outcome, 5%–10% (median 9%) have intracerebral hematoma (ICH), and 25%–35% (median 30%) have death/bad outcome. Two neurologists from a tertiary care hospital in the region treated 122 cases of ischemic strokes with IVTT from 2012 to 2016. Age ranged from 8 to 88 years and 88 were males. Average delay in reaching hospital was 138.1 min and the door-to-needle time was 56.3 min. There were 26 cases of posterior-circulation strokes and 14 cases of cardioembolic strokes. At presentation, average National Institute of Health Stroke Scale (NIHSS) was 14.7; Modified Rankin Scale (mRS) 0.4; and CT Alberta Stroke Program Early Computerized Tomography Scores was 9.5. Good and sustained benefit (GSB) (>4 reduction in NIHSS at 24 h and 7 days) was there in 49% and no improvement (NI)/worsening in 36%. mRS 0–2 at discharge/30 days was documented in 57.3%. Symptomatic ICH was 10% (12/122) and mortality rate was 11.5% (14/122). GSB in posterior circulation strokes was 69.2% and NI/worsening in only 7.7%. mRS was 0–2 in 77% of posterior circulation strokes.Conclusion:Contrary to the popular belief of the practicing neurologists, IVTT has a high percentage of good outcome with a reasonable bleeding risk and low rates of absolute futility.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Real-World Effectiveness of Intravenous Stroke Thrombolysis is more than the Expectation of Practicing Neurologists

Ghafoor

Khan

Shehna

2018

Journal of Neurosciences in Rural Practice

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“…In 1995, the National Institute of Neurological Disorders and Stroke (NINDS) stroke trial was published, and it has since been credited as one of the most crucial final steps in getting tPA FDA approved in 1996 [67].…”

Section: Future Prospects: Replicating the Ninds Studymentioning

confidence: 99%

Minocycline: A Novel Stroke Therapy

Møller¹

2015

JNSK

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“…The neurologic training within emergency medicine (EM) residency programs has previously been described as highly variable; therefore, some EPs and non‐EM residency–trained physicians may have limited experience or specific education with acute stroke protocols 7,8 . They are also concerned about potential complications of tPA treatment, particularly intracranial hemorrhage (ICH), 4 and the medico legal risk associated with either inappropriate treatment or failure to treat 9 …”

mentioning

confidence: 99%

Observational Study of Telephone Consults by Stroke Experts Supporting Community Tissue Plasminogen Activator Delivery

Majersik

Meurer

Frederiksen

et al. 2012

Academic Emergency Medicine

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Objectives Barriers to intravenous (IV) tissue plasminogen activator (tPA) use in ischemic stroke include limited treatment experience of community physicians. Models of acute stroke care have been designed to address these limitations by providing community support. These include support by telephone or televideo, with or without subsequent transport to tertiary care centers. The authors describe the frequency, characteristics, and effect of community phone consultations to a 24/7 stroke “hotline” staffed by stroke physicians at an academic stroke center using such a model. Methods Twelve intervention hospitals participating in the INcreasing Stroke Treatment through Interventional behavior Change Tactics (INSTINCT) trial were provided a single-access number (“hotline”) for expert consultation on tPA use. Experts consisted of stroke-trained physicians at an academic medical center. Hotline use was not mandated by the study protocol, nor was patient transfer required. Consultants were required to record all treatment questions in a web-based log. All patients discussed over the hotline and/or treated with tPA in an INSTINCT hospital underwent multi-level chart review by trained nurse coordinators. Cases were linked to logged hotline calls, based on the time of treatment and the initial treating hospital. Physician adjudicators assessed appropriateness of tPA treatment, presence of deviation from standard guidelines, and treatment complications (intracranial hemorrhage [ICH], systemic hemorrhage, or death). Results Over 27 months, there were a total of 204 hotline calls regarding 116 patients. Ninety-one percent of calls were between 8 am and midnight, 77% of questions explored issues of eligibility for IV tPA, particularly for minor stroke or improving stroke (26%). A total of 243 patients were treated with IV tPA at the 12 intervention hospitals, 54 of which were following hotline consult. Seventy-six percent of hotline patients in whom tPA was recommended actually received tPA, while 2% of those in whom tPA was not recommended received the medication. There were no differences in protocol deviations (27.8% hotline group vs. 23.8% non-hotline group), incidence of symptomatic ICH (5.6% vs. 7.3%), or in-hospital mortality (5.6% vs. 13.2%). No medical-legal issues have been reported for any case in the study. Conclusions Providing tPA decision-making support via telephone consult to community physicians is feasible and safe. Consultants may play a more prominent role in determining tPA ineligibility than acceptance. Future work should include a real-time survey of physician providers to ascertain such potential qualitative benefits of a stroke hotline.

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Medico-Legal Aspects of Using Tissue Plasminogen Activator in Acute Ischemic Stroke

Cited by 14 publications

References 18 publications

Real-World Effectiveness of Intravenous Stroke Thrombolysis is more than the Expectation of Practicing Neurologists

Real-World Effectiveness of Intravenous Stroke Thrombolysis is more than the Expectation of Practicing Neurologists

Minocycline: A Novel Stroke Therapy

Observational Study of Telephone Consults by Stroke Experts Supporting Community Tissue Plasminogen Activator Delivery

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