Intravenous thrombolysis is one of the most effective treatments we have for acute ischemic stroke. The established guidelines for administering tPA do not and cannot address every single clinical situation in which tPA should be considered. Given its integral role in treatment of stroke, it is valuable to continue to evaluate different clinical situations in which IV tPA may be effective.
Qureshi and his team looked at the use of IV tPA in patients with acute ischemic stroke with infective endocarditis (IE). They examined data from the Nationwide Inpatient Sample (NIS) from 2002-2010 to determine the rates and outcomes of ischemic stroke patients with IE treated with IV tPA. Outcomes were defined as rates of post-thrombolytic ICH and favorable outcome (discharge disposition of home/self-care). They found that the rate of post-thrombolytic ICH was significantly higher and the rate of favorable outcome was significantly lower in patients with IE as compared to patients without IE.
The study highlights the fact that caution and careful decision making should be used when considering intravenous thrombolysis in patients with acute ischemic stroke and with IE, but beyond that, it is difficult to apply their data and findings to specific clinical situations. As Qureshi’s team acknowledges, because their data is extracted from the NIS, we don’t have access to certain information that would have been helpful in this study. When was the diagnosis of IE made in relationship to diagnosis of stroke and administration of tPA? What was the patient’s level of functioning prior to hospitalization? What was the degree of neurological deficit at time of treatment? What was the door to needle time? What was the severity of the ICH after tPA? These questions are relevant when considering the utility of administering tPA in situations that do not yet have clearly defined guidelines.
This paper directs our attention to the potential risks of tPA in patients with acute stroke and IE and emphasizes the need for careful clinical decision making. It also leaves us hungry for more research in this area.