Protocol violations in community-based rTPA stroke treatment are associated with symptomatic intracerebral hemorrhage.
BACKGROUND
Recombinant tissue plasminogen activator (rTPA) is an established treatment for acute ischemic stroke. The rate and type of protocol violations in rTPA use and their effect on patient outcomes in this setting are not well understood.


OBJECTIVE
The objective of this study was to examine associations between protocol violations and outcomes in community-based rTPA use.


METHODS
We reviewed medical records of stroke patients treated with rTPA in 10 acute-care hospitals in Indianapolis from July 1996 to February 1998 and assessed complications and outcome. Retrospective National Institute of Health Stroke Scale (on admission and discharge), Canadian Neurological Scale, and length of hospital stay were calculated. Appropriate use of rTPA was determined by the National Institute of Neurological Disorders and Stroke (NINDS) protocol.


RESULTS
Fifty patients (mean age, 66 years; 76% white; 56% men) were treated by general neurologists (70%), stroke neurologists (24%), or emergency physicians (6%). Mean times to hospital arrival, brain CT, and start of rTPA infusion were 44, 86, and 141 minutes, respectively. In-hospital mortality rate was 10% (4 intracerebral hemorrhage [ICH], 1 cardiogenic shock). Complications were more frequent among patients with protocol violations (n=8) compared with those without all hemorrhages (75% versus 10%, P:<0.001), symptomatic ICH (38% versus 5%, P:<0.02), and ICH attributable to rTPA, occurring within 36 hours (38% versus 2.4%, P:<0.01), respectively.


CONCLUSIONS
NINDS protocol violations are relatively common and are associated with symptomatic cerebral and systemic hemorrhages. When the NINDS protocol is strictly followed, hemorrhage rates in community-based rTPA use are similar to those in the NINDS trial.
Lopez-Yunez
A M
AM
Department of Neurology, Indiana University School of Medicine, Indianapolis, IN 46202, USA. alopez1@iupui.edu
Bruno
A
A
Williams
L S
LS
Yilmaz
E
E
Zurrú
C
C
Biller
J
J
D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects / Q000528:radiation effects; D002543:Cerebral Hemorrhage / Q000453:epidemiology / Q000209:etiology*; D002986:Clinical Trials as Topic; D003710:Demography; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D007196:Indiana / Q000453:epidemiology; D007275:Injections, Intravenous; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010976:Platelet Count; D011994:Recombinant Proteins / Q000009:adverse effects; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000145:classification / Q000188:drug therapy* / Q000401:mortality; D015996:Survival Rate; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects*
D000925:Anticoagulants; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator