Current evidence suggests that, in a small subset of acute stroke patients who can be treated within 3 hours of symptom onset, the administration of tissue plasminogen activator (tPA) confers a modest outcome benefit, but that this benefit is associated with an increased risk of intracranial hemorrhage that can be severe or fatal. The data show that tPA therapy must be limited to carefully selected patients within established protocols. Further evidence is necessary to support the widespread application of stroke thrombolysis outside research settings. Until it is clear that the benefits of this therapy outweigh the risks, thrombolytic therapy for acute stroke should be restricted to use within formal research protocols or in monitored practice protocols that adhere to the NINDS (the rt-PA Stroke Study Group trial of the National Institute of Neurological Disorders and Stroke) eligibility criteria. All data on protocol compliance and patient outcomes should be collated in a central Canadian registry for the purposes of tracking safety and efficacy.
Stroke thrombolysis should be limited to centers with appropriate neurological and neuro-imaging resources that are capable of administering treatment within 3 hours. In such centres, emergency physicians should identify eligible patients, initiate low risk interventions and facilitate prompt computed tomography. Only physicians with demonstrated expertise in neuroradiology should interpret head CT scans used to determine whether to administer thrombolytic agents to stroke patients. Neurologists should be directly involved prior to the thrombolytic administration.