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Published on December 05, 2016

Speed dial 911, if you suspect strokeSpeed dial 911, if you suspect stroke

More than 795,000 people in the United States suffer an acute stroke every year, according to the Centers for Disease Control and Prevention (CDC). And the only Federal Drug Administration (FDA) approved medication to treat it is tPA (tissue plasminogen activator), also known as Alteplase.

The drug is used to treat ischemic strokes, which comprise about 80 percent of all strokes, according to Michael Markowski, DO, FAAN, a neurologist at Cape Cod Hospital.

“The relative benefit of receiving Alteplase is reduced disability at three months and beyond,” he said. “One out of three people will have minimal to no disability. If we treat 100 patients with Alteplase, 32 will benefit, and three will have adverse effects. We’re not helping everybody, but this is the only medication we have to treat ischemic stroke, so we want to use it when able.”

Alteplase works by breaking up the clot that is blocking the vessel and cutting off oxygen to the brain. While it is available to all ischemic stroke patients, only 10 percent of patients in the United States receive the treatment, according to Dr. Markowski. The reason is that only about 22 percent of patients come into the emergency room within the limited time window required for safe administration of the drug, he said.

When Alteplase Is Used

The time for giving the medication begins when the symptoms of the stroke start, so getting to the emergency room as soon as possible is crucial.

The treatment window is longer if you are under the age of 80. Those patients may be treated with Alteplase up to four and one-half hours from the onset of symptoms. For patients over 80, Alteplase can only be given safely within three hours of stroke onset.

“There are very strict criteria for administering the medication, and the four-and-a-half-hour time window is the most stringent of the criteria,” Dr. Markowski said.

The acronym FAST is one way to remember symptoms that could indicate a stroke, according to the American Stroke Association:

  • Face drooping
  • Arm weakness
  • Speech difficulty
  • Time to call 911

“An important point to remember is that the symptoms will commonly affect one side of the body,” said Dr. Markowski.

After your arrival in the emergency room, many assessments will happen very fast. You will have a neurological assessment by the emergency room physician, lab work will be drawn, a head CT scan will be done, medical history taken and another neurological exam after your CT scan and brain artery imaging.

“Our goal is to make sure there are no contraindications to giving the Alteplase and to administer it within 60 minutes of the patient’s arrival in the emergency room,” said Dr. Markowski.

Some of the criteria to receiving Alteplase include:

When you can receive Alteplase

  • The stroke is an ischemic stroke and not a hemorrhagic stroke (bleeding in the brain)
  • Your platelet count is normal
  • Your blood pressure is not markedly elevated
  • Head CT scan is normal (no bleeding)
  • You meet the time window, among many other criteria

When Alteplase cannot be given

  • Your stroke is a result of bleeding in your brain (hemorrhagic stroke)
  • You have uncontrolled high blood pressure (this may be treated with IV medications in the ER to bring it down so you can receive Alteplase)
  • Your platelet count is low, this would increase your risk for bleeding
  • You are taking blood thinners such as Warfarin (Coumadin), Pradaxa, Xarelto or Eliquis among certain others

Other reasons you may not qualify for Alteplase is that your symptoms are due to another disorder which may mimic stroke in some cases, which may rarely occur with migraines or seizures. Migraine disorders and partial seizure disorders may cause focal weakness or numbness on one side of the body along with abnormalities of vision and speech which rarely may mimic stroke symptoms.

Another Tool to Prevent Disability

Mechanical thrombectomy is a more recent procedure approved to treat ischemic stroke in addition to Alteplase,” said Dr. Markowski. Alteplase has been available since the 1990s to treat ischemic stroke and mechanical thrombectomy became available for stroke patients in 2015. It is a procedure to remove blockages of larger blood vessels and is completed by a physician who is a specialist in interventional procedures, typically within academic hospitals.

The physician removes the clot by going through a catheter inserted into the groin to access the artery blockage within the neck or brain causing the stroke. To reduce the risk of complications, this procedure should ideally be completed within six hours of stroke symptom onset. However, it may rarely be completed in certain patients up to 24 hours of symptom onset. This procedure is commonly completed after Alteplase has been given first intravenously. At Cape Cod Hospital in Hyannis, one to two patients per month are transferred to Boston to complete mechanical thrombectomy.

The benefit of this procedure is greater than intravenous Alteplase, said Dr. Markowski. However, less stroke patients will be candidates for mechanical thrombectomy in comparison to those eligible to receive intravenous Alteplase. This procedure is only completed for patients with stroke caused by blockages within the larger arteries of the neck and brain, which occurs in approximately 10 percent of stroke patients.

“The absolute benefit of Alteplase is 12 percent, whereas the addition of the mechanical thrombectomy raises the benefit between 20 to 30 percent,” leading to less neurological deficits and disability, he said.

“Time is Brain,” said Dr. Markowski and the sooner patients arrive to the hospital after stroke onset, the better their outcome with these available treatments.

Article updated 3/22/22