title: Intravenous fibrinolysis eligibility: a survey of stroke clinicians' practice patterns and review of the literature.
abstract: BACKGROUND
  The indications and contraindications for intravenous (IV) recombinant tissue plasminogen activator (rtPA) use in ischemic stroke can be confusing to the practicing neurologist. Here we seek to describe practice patterns regarding decision-making among US stroke clinicians.
  
  
  METHODS
  Stroke clinicians (attending and fellow) from the 8 National Institutes of Health SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) centers were asked to complete a survey ahead of the 2012 SPOTRIAS Investigators' meeting.
  
  
  RESULTS
  A total of 51 surveys were collected (71% response rate). Most of the responders were attending physicians (68%). Only 18% of clinicians reported strictly adhering to current American Heart Association guidelines for treatment within 3 hours from symptom onset; this increased to 51% for the European Cooperative Acute Stroke Study (ECASS) III criteria in the 3 to 4.5 hours time frame. All clinicians treat eligible patients in the 3 to 4.5 hours time frame. The great majority will recommend rtPA in the following scenarios: (1) elderly individuals irrespective of age (97%); (2) severe stroke irrespective of National Institutes of Health Stroke Scale (NIHSS) (95%); or (3) suspected stroke with seizures at symptom onset (91%). None recommended rtPA in the setting of an international normalized ratio >1.7. Most clinicians defined mild strokes as an exclusion based on the perceived disability of the deficit (80%) rather than on a specific NIHSS threshold.
  
  
  CONCLUSIONS
  Most surveyed stroke clinicians seem to find that the current IV rtPA eligibility criteria for the 3-hour time frame too restrictive. All would recommend rtPA to eligible patients in the 3 to 4.5 hours time frame despite the absence of an U.S. Food and Drug Administration (FDA)-approved indication.
authors.affiliation: Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Neurology, Sanna Healthcare Network, Lima, Peru. Electronic address: delosrfe@ucmail.uc.edu.
authors.forename: Felipe
authors.initials: F
authors.lastname: De Los Rios
authors.affiliation: Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
authors.forename: Dawn O
authors.initials: DO
authors.lastname: Kleindorfer
authors.affiliation: Department of Neuroscience, University of California San Diego, San Diego, California.
authors.forename: Amy
authors.initials: A
authors.lastname: Guzik
authors.affiliation: Department of Neurology, Columbia University, New York, New York.
authors.forename: Santiago
authors.initials: S
authors.lastname: Ortega-Gutierrez
authors.affiliation: Department of Neurology, University of Texas, Houston, Texas.
authors.forename: Navdeep
authors.initials: N
authors.lastname: Sangha
authors.affiliation: Department of Neurology, Washington University, St. Louis, Missouri.
authors.forename: Gyanendra
authors.initials: G
authors.lastname: Kumar
authors.affiliation: Department of Neurology, University of Texas, Houston, Texas.
authors.forename: James C
authors.initials: JC
authors.lastname: Grotta
authors.affiliation: Department of Neurology, Washington University, St. Louis, Missouri.
authors.forename: Jin-Moo
authors.initials: JM
authors.lastname: Lee
authors.affiliation: Department of Neuroscience, University of California San Diego, San Diego, California.
authors.forename: Brett C
authors.initials: BC
authors.lastname: Meyer
authors.affiliation: Department of Neurology, Harvard Medical School, Boston, Massachussets.
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
authors.affiliation: Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
authors.forename: Pooja
authors.initials: P
authors.lastname: Khatri
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000375:Aging / Q000187:drug effects*; D003625:Data Collection; D004608:Eligibility Determination / Q000592:standards* / Q000706:statistics & numerical data; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010820:Physicians; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D012196:Review Literature as Topic; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods / Q000592:standards*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator
keywords: Stroke; infarction; rtPA; stroke treatment; thrombolysis; tissue plasminogen activator
references.citation: Eur J Neurol. 2012 Mar;19(3):390-4
references.pmid: 21895883
references.citation: Stroke. 2011 Apr;42(4):1041-5
references.pmid: 21350204
references.citation: Stroke. 2012 Feb;43(2):563-6
references.pmid: 21998057
references.citation: Stroke. 2009 Aug;40(8):2945-8
references.pmid: 19478221
references.citation: Stroke. 2012 Feb;43(2):412-6
references.pmid: 22156701
references.citation: JAMA. 2012 Jun 27;307(24):2600-8
references.pmid: 22735429
references.citation: Lancet. 2012 Jun 23;379(9834):2352-63
references.pmid: 22632908
references.citation: Lancet. 2012 Jun 23;379(9834):2364-72
references.pmid: 22632907
references.citation: N Engl J Med. 1995 Dec 14;333(24):1581-7
references.pmid: 7477192
references.citation: Stroke. 2007 May;38(5):1655-711
references.pmid: 17431204
references.citation: JAMA. 2000 Mar 1;283(9):1151-8
references.pmid: 10703777
references.citation: Stroke. 2007 Feb;38(2):417-22
references.pmid: 17185641
references.citation: Stroke. 2003 Mar;34(3):799-800
references.pmid: 12624312
references.citation: Lancet. 2004 Mar 6;363(9411):768-74
references.pmid: 15016487
references.citation: Stroke. 2010 Jul;41(7):1450-8
references.pmid: 20538701
references.citation: Stroke. 2012 Jun;43(6):1591-5
references.pmid: 22442174
references.citation: J Cereb Blood Flow Metab. 2012 Jul;32(7):1416-25
references.pmid: 22510604
references.citation: Stroke. 2009 Jul;40(7):2568-71
references.pmid: 19423853
references.citation: Stroke. 2011 Jul;42(7):1952-5
references.pmid: 21636813
references.citation: Swiss Med Wkly. 2004 Jan 10;134(1-2):14-7
references.pmid: 14745662
references.citation: Stroke. 2013 Mar;44(3):870-947
references.pmid: 23370205
references.citation: Am J Prev Med. 2006 Dec;31(6 Suppl 2):S210-6
references.pmid: 17178305
references.citation: N Engl J Med. 2013 Mar 7;368(10):914-23
references.pmid: 23394476
references.citation: Stroke. 2012 Jun;43(6):1684-6
references.pmid: 22535272
references.citation: Cerebrovasc Dis. 2012;34(2):115-20
references.pmid: 22854315
references.citation: Neurology. 2011 May 24;76(21):1838-40
references.pmid: 21490319
references.citation: Stroke. 2007 Sep;38(9):2612-8
references.pmid: 17656661
references.citation: Neurology. 2011 May 24;76(21):1780-1
references.pmid: 21490320
references.citation: Neurology. 2010 Apr 27;74(17):1340-5
references.pmid: 20335564
references.citation: Neurology. 1998 Jun;50(6):1857-9
references.pmid: 9633741
references.citation: J Neuroimaging. 2012 Apr;22(2):197-200
references.pmid: 21143548
references.citation: Lancet. 2010 May 15;375(9727):1695-703
references.pmid: 20472172
references.citation: Neurocrit Care. 2012 Oct;17(2):199-203
references.pmid: 22752394
references.citation: Arch Neurol. 2010 May;67(5):559-63
references.pmid: 20212195
references.citation: N Engl J Med. 2008 Sep 25;359(13):1317-29
references.pmid: 18815396
references.citation: Rev Neurol (Paris). 2009 May;165(5):471-8
references.pmid: 19124142
references.citation: Neuroimaging Clin N Am. 2011 May;21(2):247-57, ix-x
references.pmid: 21640298