A Regional System of Stroke Care Provides Thrombolytic Outcomes Comparable With the NINDS Stroke Trial
Received 17 July 2007; received in revised form 4 January 2008 and 25 August 2008; accepted 23 September 2008. published online 22 December 2008.
Study objective
Administration of tissue plasminogen activator (tPA) for acute ischemic stroke remains controversial in community practice. Well-organized hierarchic systems of acute stroke care have been proposed to link community hospitals to comprehensive stroke centers. We report safety and functional outcomes in patients treated with tPA in our regional emergency stroke network and compare them with results reported from the trial conducted by the National Institute of Neurological Disorders and Stroke (NINDS).
Methods
Through a statewide communications and transport network, our brain attack center gives emergency medicine staff in the state and surrounding area immediate access to stroke specialists. The team provides consultation about the administration of tPA for ischemic stroke, using the NINDS protocol. Consultations, treatment, and outcomes are documented in our database.
Results
From 1996 to 2005, the brain attack center completed 2,670 consultations and diagnosed 1,788 patients with ischemic stroke. Two hundred forty patients (9% of all consultations; 13.4% of those with acute ischemic stroke) received tPA. Percentages of patients with symptomatic intracranial hemorrhage and 3-month modified Rankin scale scores less than or equal to 1, compared with those in the NINDS trial, were as follows: 3.3% versus 6.4% and 53% versus 43% (P=.04). Mortality rates were 13% (network) versus 17% (NINDS).
Conclusion
During a 9-year period, an emergency medicine network with stroke consultants achieved patient outcomes comparable to those reported from the NINDS trial. These results indicate that the NINDS tPA protocol is applicable to community practice, with the support of a university-based brain attack center.
aDepartment of Neurology, University of Maryland School of Medicine, Baltimore, MD
bDepartment of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, MD
cDepartment of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
dUniversity of Maryland School of Nursing and the University of Maryland Medical Center, Baltimore, MD
eMaryland Institute for Emergency Medical Services Systems, Baltimore, MD
Address for correspondence: Marian P. LaMonte, MD, MSN, Division of Neurology, St. Agnes Hospital, 3421 Benson Avenue, Suite 240, Baltimore, MD 21227; 410-368-8444, fax 410-368-8432
Supervising editor: Robert Silbergleit, MD
The article was copyedited by Linda J. Kesselring, MS, ELS, the technical editor/writer in the Department of Emergency Medicine at the University of Maryland School of Medicine.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
Publication date: Available online December 19, 2008.
Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com.
Reprints not available from the authors.
Dr. LaMonte is currently affiliated with the Division of Neurology, St. Agnes Hospital, Baltimore, MD.
ABSTRACT
A Regional System of Stroke Care Provides Thrombolytic Outcomes Comparable With the NINDS Stroke Trial