title: Treatment with tissue plasminogen activator is not associated with increased use of neurosurgery.
abstract: BACKGROUND
  Current guidelines of stroke care imply that tissue plasminogen activator (rtPA) should be only used in centers with a neurosurgeon available to manage any intracranial hemorrhage (ICH). Such advice may be difficult to follow with the current US shortage of neurosurgeons. It could also contribute to the underutilization of rtPA in smaller hospitals and might not be justified if, in practice, most ICHs were managed medically.
  
  
  METHODS
  Using the Health Cost Utilization Project 2000 sample we studied the relationship among ischemic stroke, ICH, and rtPA.
  
  
  RESULTS
  In this sample of 7,450,992 hospital admissions, 1516 patients had both ischemic stroke and ICH. Among these patients, 58 had received rtPA and 5 of those (8.6%) had a neurosurgical intervention. In the remaining 1458 patients who did not receive rtPA, 178 (12.2%) had neurosurgery. Therefore, the odds ratio for having a neurosurgical intervention for ICH after rtPA was 0.68 (95% confidence interval: 0.27-1.7).
  
  
  CONCLUSIONS
  In this large sample of US hospital admissions as a result of acute ischemic stroke with overlapping hemorrhage, the use of rtPA was not associated with an increased number of neurosurgical interventions. This lack of association, which needs to be confirmed in prospective studies, argues against withholding treatment with rtPA in patients with stroke based on neurosurgical availability.
authors: Souers Stroke Institute, Department of Neurology, Saint Louis University, St Louis, Missouri, USA.
authors: Enrique C
authors: EC
authors: Leira
authors: Salvador
authors: S
authors: Cruz-Flores
authors: Aninda B
authors: AB
authors: Acharya
authors: Yi
authors: Y
authors: Pan