UPDATE ON THROMBOLYTIC THERAPY Markku Kaste Department of Neurology Helsinki University Central Hospital (HUCH) University of Helsinki Markku Kaste Department.

UPDATE ON THROMBOLYTIC UPDATE ON THROMBOLYTIC THERAPYTHERAPY

UPDATE ON THROMBOLYTIC UPDATE ON THROMBOLYTIC THERAPYTHERAPY

Markku KasteMarkku Kaste

Department of NeurologyDepartment of Neurology

Helsinki University Central Hospital (HUCH) Helsinki University Central Hospital (HUCH)

University of HelsinkiUniversity of Helsinki

Markku KasteMarkku Kaste

Department of NeurologyDepartment of Neurology

Helsinki University Central Hospital (HUCH) Helsinki University Central Hospital (HUCH)

University of HelsinkiUniversity of Helsinki

Topics of my presentationTopics of my presentationTopics of my presentationTopics of my presentation

• The pooled analysis of ATLANTIS, ECASS and The pooled analysis of ATLANTIS, ECASS and NINDS trialsNINDS trials

• Cochrane systematic reviewCochrane systematic review

• Thrombolysis in clinical practice at HUCHThrombolysis in clinical practice at HUCH

• Graham´s meta-analysis of 12 open seriesGraham´s meta-analysis of 12 open series

• Ongoing trialsOngoing trials

• New trials New trials

- SITS-MOST- SITS-MOST

- ECASS III- ECASS III

• The pooled analysis of ATLANTIS, ECASS and The pooled analysis of ATLANTIS, ECASS and NINDS trialsNINDS trials

• Cochrane systematic reviewCochrane systematic review

• Thrombolysis in clinical practice at HUCHThrombolysis in clinical practice at HUCH

• Graham´s meta-analysis of 12 open seriesGraham´s meta-analysis of 12 open series

• Ongoing trialsOngoing trials

• New trials New trials

- SITS-MOST- SITS-MOST

- ECASS III- ECASS III

IS THERE BENEFIT AFTER IS THERE BENEFIT AFTER 3 HOURS? 3 HOURS?

A Pooled Analysis of the A Pooled Analysis of the ATLANTIS, ECASS, ATLANTIS, ECASS,

and NINDS rtPA Stroke Trialsand NINDS rtPA Stroke Trials

IS THERE BENEFIT AFTER IS THERE BENEFIT AFTER 3 HOURS? 3 HOURS?

A Pooled Analysis of the A Pooled Analysis of the ATLANTIS, ECASS, ATLANTIS, ECASS,

and NINDS rtPA Stroke Trialsand NINDS rtPA Stroke Trials

The ATLANTIS, ECASS, and NINDS The ATLANTIS, ECASS, and NINDS Study Group Investigators Study Group Investigators

The ATLANTIS, ECASS, and NINDS The ATLANTIS, ECASS, and NINDS Study Group Investigators Study Group Investigators

RationaleRationaleRationaleRationale

• Quicker administration of IV rtPA improved Quicker administration of IV rtPA improved outcomes in prior individual trialsoutcomes in prior individual trials

• We hypothesized that combined analysis We hypothesized that combined analysis of those trials would confirm a stroke-of those trials would confirm a stroke-onset-to-treatment time effectonset-to-treatment time effect

• We hypothesized that a pooled analysis We hypothesized that a pooled analysis could suggest whether thrombolysis is could suggest whether thrombolysis is beneficial after 3 hours?beneficial after 3 hours?

• Quicker administration of IV rtPA improved Quicker administration of IV rtPA improved outcomes in prior individual trialsoutcomes in prior individual trials

• We hypothesized that combined analysis We hypothesized that combined analysis of those trials would confirm a stroke-of those trials would confirm a stroke-onset-to-treatment time effectonset-to-treatment time effect

• We hypothesized that a pooled analysis We hypothesized that a pooled analysis could suggest whether thrombolysis is could suggest whether thrombolysis is beneficial after 3 hours?beneficial after 3 hours?

MethodsMethodsMethodsMethods

• Original individual patient data were Original individual patient data were pooled from 6 randomized controlled trialspooled from 6 randomized controlled trials

• Method differs from meta-analysis where Method differs from meta-analysis where individual patient data are not generally individual patient data are not generally available and limited adjustment for available and limited adjustment for co-variates is possible co-variates is possible

• Original individual patient data were Original individual patient data were pooled from 6 randomized controlled trialspooled from 6 randomized controlled trials

• Method differs from meta-analysis where Method differs from meta-analysis where individual patient data are not generally individual patient data are not generally available and limited adjustment for available and limited adjustment for co-variates is possible co-variates is possible

Results IResults IResults IResults I

• 2776 patients2776 patients

• Over 300 hospitalsOver 300 hospitals

• 18 countries18 countries

• Median age 68 yearsMedian age 68 years

• Median baseline NIHSSS 12Median baseline NIHSSS 12

• 2776 patients2776 patients

• Over 300 hospitalsOver 300 hospitals

• 18 countries18 countries

• Median age 68 yearsMedian age 68 years

• Median baseline NIHSSS 12Median baseline NIHSSS 12

Global Outcome (mRS 0-1, BI 95-100, NIHH 0-1) at Day 90

Adjusted odds ratio with 95% confidence interval by stroke onset to treatment time (OTT) ITT population (N=2776)

Results IIIResults IIIResults IIIResults III

Odds Ratios for Favorable OutcomeOdds Ratios for Favorable Outcome

TimeTime Odds RatioOdds Ratio 95% Conf. 95% Conf. IntervalInterval

0-900-90 2.82.8 1.8 - 4.51.8 - 4.5

91-18091-180 1.51.5 1.1 - 2.11.1 - 2.1

181-270181-270 1.41.4 1.1 - 1.91.1 - 1.9

271-360271-360 1.21.2 0.9 - 1.50.9 - 1.5

Odds Ratios for Favorable OutcomeOdds Ratios for Favorable Outcome

TimeTime Odds RatioOdds Ratio 95% Conf. 95% Conf. IntervalInterval

0-900-90 2.82.8 1.8 - 4.51.8 - 4.5

91-18091-180 1.51.5 1.1 - 2.11.1 - 2.1

181-270181-270 1.41.4 1.1 - 1.91.1 - 1.9

271-360271-360 1.21.2 0.9 - 1.50.9 - 1.5

mRS 5-6 at Day 90mRS 5-6 at Day 90Adjusted odds ratio with 95% confidence interval by Adjusted odds ratio with 95% confidence interval by

stroke stroke onset to treatment time (OTT) ITT population onset to treatment time (OTT) ITT population

(N=2776)(N=2776)

mRS 5-6 at Day 90mRS 5-6 at Day 90Adjusted odds ratio with 95% confidence interval by Adjusted odds ratio with 95% confidence interval by

stroke stroke onset to treatment time (OTT) ITT population onset to treatment time (OTT) ITT population

(N=2776)(N=2776)

All Studies

ECASS 2

ECASS 2ECASS 23-4.5 hour population3-4.5 hour population

ECASS 2ECASS 23-4.5 hour population3-4.5 hour population

mRs 0-1 mRs 6

rtPA 39.7% 7.6%

Placebo 29.8% 15.7%

Absolutedifference infavor of rtPA

9.9% 8.1%

mRs 0-1 mRs 6

rtPA 39.7% 7.6%

Placebo 29.8% 15.7%

Absolutedifference infavor of rtPA

9.9% 8.1%

Results VResults VResults VResults V

• PH2 occurred in 5.8% of rtPA-treated PH2 occurred in 5.8% of rtPA-treated patients compared to 1.1% of placebo-patients compared to 1.1% of placebo-treated patients (p<.01), median age 72treated patients (p<.01), median age 72

• PH2 was not associated with onset-to-PH2 was not associated with onset-to-treatment timetreatment time

• PH2 was associated with rtPA treatment PH2 was associated with rtPA treatment (p=.0001) and age (p=.0002)(p=.0001) and age (p=.0002)

• PH2 occurred in 5.8% of rtPA-treated PH2 occurred in 5.8% of rtPA-treated patients compared to 1.1% of placebo-patients compared to 1.1% of placebo-treated patients (p<.01), median age 72treated patients (p<.01), median age 72

• PH2 was not associated with onset-to-PH2 was not associated with onset-to-treatment timetreatment time

• PH2 was associated with rtPA treatment PH2 was associated with rtPA treatment (p=.0001) and age (p=.0002)(p=.0001) and age (p=.0002)

Conclusions IConclusions IConclusions IConclusions I

• The quicker rtPA is given to stroke The quicker rtPA is given to stroke patients, the greater the benefitpatients, the greater the benefit

• The quicker rtPA is given to stroke The quicker rtPA is given to stroke patients, the greater the benefitpatients, the greater the benefit

Conclusions IIConclusions IIConclusions IIConclusions II

• Individual studies designed to detect Individual studies designed to detect benefit from IV rtPA initiated beyond 3 benefit from IV rtPA initiated beyond 3 hours have been negative; our results hours have been negative; our results suggest they were underpoweredsuggest they were underpowered

• This pooled analysis suggests a potential This pooled analysis suggests a potential for treatment benefit beyond 3 hoursfor treatment benefit beyond 3 hours

• A randomized trial is needed to find out A randomized trial is needed to find out whether thrombolysis from 3 to 4 or 4.5 whether thrombolysis from 3 to 4 or 4.5 hours improves the outcome of stroke hours improves the outcome of stroke patients patients

• Individual studies designed to detect Individual studies designed to detect benefit from IV rtPA initiated beyond 3 benefit from IV rtPA initiated beyond 3 hours have been negative; our results hours have been negative; our results suggest they were underpoweredsuggest they were underpowered

• This pooled analysis suggests a potential This pooled analysis suggests a potential for treatment benefit beyond 3 hoursfor treatment benefit beyond 3 hours

• A randomized trial is needed to find out A randomized trial is needed to find out whether thrombolysis from 3 to 4 or 4.5 whether thrombolysis from 3 to 4 or 4.5 hours improves the outcome of stroke hours improves the outcome of stroke patients patients

COCHRANE SYSTEMATIC COCHRANE SYSTEMATIC REVIEWREVIEW

COCHRANE SYSTEMATIC COCHRANE SYSTEMATIC REVIEWREVIEW

Joanna WardlawJoanna Wardlaw

Department of NeurologyDepartment of Neurology

University of EdinburghUniversity of Edinburgh

Joanna WardlawJoanna Wardlaw

Department of NeurologyDepartment of Neurology

University of EdinburghUniversity of Edinburgh

rt-PA : other drugsrt-PA : other drugs

better thrombolysis worse

0.1 0.66 0.84 1.0 1.33 3.37 10 OR

Symptomatic ICH(n = 2955)

Dead(n = 2955)

Dead or Dependent0 - 6 hours (n = 2830)

Dead or Dependent0 - 3 hours (n = 957)

+62

- 55

-110

+19 (NS)

Effect per 1000

= OR for ALL agents

(n= ) = n with tPA

Rt-PA: time windows: Rt-PA: time windows: poor functional outcomespoor functional outcomes

Rt-PA: time windows: Rt-PA: time windows: poor functional outcomespoor functional outcomes

rt-PA for acute ischemic rt-PA for acute ischemic hemispheric stroke in clinical hemispheric stroke in clinical

practicepractice at HUCH at HUCH

rt-PA for acute ischemic rt-PA for acute ischemic hemispheric stroke in clinical hemispheric stroke in clinical

practicepractice at HUCH at HUCH

Markku KasteMarkku Kaste

Department of Neurology,Department of Neurology,

Helsinki University Central Hospital (HUCH)Helsinki University Central Hospital (HUCH)

University of HelsinkiUniversity of Helsinki

Markku KasteMarkku Kaste

Department of Neurology,Department of Neurology,

Helsinki University Central Hospital (HUCH)Helsinki University Central Hospital (HUCH)

University of HelsinkiUniversity of Helsinki

FUNCTIONAL OUTCOME OF THROMBOLYTIC FUNCTIONAL OUTCOME OF THROMBOLYTIC THERAPY THERAPY

IN HEMISPHERIC STROKEIN HEMISPHERIC STROKE- - RANKIN SCALE AT 3 MONTHSRANKIN SCALE AT 3 MONTHS

FUNCTIONAL OUTCOME OF THROMBOLYTIC FUNCTIONAL OUTCOME OF THROMBOLYTIC THERAPY THERAPY

IN HEMISPHERIC STROKEIN HEMISPHERIC STROKE- - RANKIN SCALE AT 3 MONTHSRANKIN SCALE AT 3 MONTHS

37

32

40

40

39

26

40

24

24

21

21

25

17

18

24

11

23

27

5

26

12

28

17

21

0 % 20 % 40 % 60 % 80 % 100 %

Helsinki (75)

CASES (1134)

Cologne (100)

ECASS 3h IT

NINDS rt-PA

NINDS placebo

0-1 2-3 4-5 DEATH

37

32

40

40

39

26

40

24

24

21

21

25

17

18

24

11

23

27

5

26

12

28

17

21

0 % 20 % 40 % 60 % 80 % 100 %

Helsinki (75)

CASES (1134)

Cologne (100)

ECASS 3h IT

NINDS rt-PA

NINDS placebo

0-1 2-3 4-5 DEATH

OUTCOME OF DEPENDENCY AFTER OUTCOME OF DEPENDENCY AFTER THROMBOLYTIC THERAPY IN HEMISPHERIC THROMBOLYTIC THERAPY IN HEMISPHERIC

STROKESTROKE- - BARTHEL INDEX AT 3 MONTHSBARTHEL INDEX AT 3 MONTHS

OUTCOME OF DEPENDENCY AFTER OUTCOME OF DEPENDENCY AFTER THROMBOLYTIC THERAPY IN HEMISPHERIC THROMBOLYTIC THERAPY IN HEMISPHERIC

STROKESTROKE- - BARTHEL INDEX AT 3 MONTHSBARTHEL INDEX AT 3 MONTHS

61

53

50

38

25

19

16

23

8

16

17

18

5

12

16

21

0 % 20 % 40 % 60 % 80 % 100 %

Helsinki (75)

Cologne (100)

NINDS rt-PA

NINDS placebo

100-95 90-55 50-0 DEATH

61

53

50

38

25

19

16

23

8

16

17

18

5

12

16

21

0 % 20 % 40 % 60 % 80 % 100 %

Helsinki (75)

Cologne (100)

NINDS rt-PA

NINDS placebo

100-95 90-55 50-0 DEATH

FREQUENCY OF HEMORRHAGIC BRAIN LESIONS FREQUENCY OF HEMORRHAGIC BRAIN LESIONS AFTER THROMBOLYTIC THERAPY IN AFTER THROMBOLYTIC THERAPY IN

HEMISPHERIC STROKEHEMISPHERIC STROKE

FREQUENCY OF HEMORRHAGIC BRAIN LESIONS FREQUENCY OF HEMORRHAGIC BRAIN LESIONS AFTER THROMBOLYTIC THERAPY IN AFTER THROMBOLYTIC THERAPY IN

HEMISPHERIC STROKEHEMISPHERIC STROKE

36

208 8

6

24

11 8

05

101520253035404550

ECASS 3hplacebo (38)

ECASS 3hrTPA (49)

Cologne (100) Helsinki (75)

% o

f co

hort

PARENCHYMAL HAEMATOMASHEMORRHAGIC TRANSFORMATIONS

36

208 8

6

24

11 8

05

101520253035404550

ECASS 3hplacebo (38)

ECASS 3hrTPA (49)

Cologne (100) Helsinki (75)

% o

f co

hort

PARENCHYMAL HAEMATOMASHEMORRHAGIC TRANSFORMATIONS

rt-PA for Acute Ischemic Stroke rt-PA for Acute Ischemic Stroke in Clinical Practice:in Clinical Practice:

A Meta-Analyasis of Safety A Meta-Analyasis of Safety DataData

rt-PA for Acute Ischemic Stroke rt-PA for Acute Ischemic Stroke in Clinical Practice:in Clinical Practice:

A Meta-Analyasis of Safety A Meta-Analyasis of Safety DataData

Glenn D. GrahamGlenn D. Graham

Albuquerque VA and University of New Mexico Albuquerque VA and University of New Mexico School of MedicineSchool of Medicine

Glenn D. GrahamGlenn D. Graham

Albuquerque VA and University of New Mexico Albuquerque VA and University of New Mexico School of MedicineSchool of Medicine

Glenn D. Graham 2002

Glenn D. Graham 2002

TrialProspective or Retrospective

Number of Patients

Median Baseline

NIHSSSymptomatic

ICH Deaths

Very Favorable Outcomes

Protocol Violations Reference

CASES P 1099 15 4.6% 15.0% 5STARS P 389 13 3.3% 13.4% 34.6% 32.6% 6Houston P 269 14 4.5% 15.0% 13.0% 7Cologne P 150 11 4.0% 10.7% 41.0% 1.3% 8Berlin P 75 13 2.7% 15.0% 40.0% 20.0% 9Cleveland P 70 12 15.7% 15.7% 50.0% 4Calgary P 68 15 8.8% 16.2% 16.2% 10OSF Stroke Network P 57 15 5.3% 8.8% 47.0% 8.8% 11Mercy / Sacramento P 43 14 7.0% 16.3% 42.0% 18.6% 12Oregon P 33 17 9.1% 18.2% 36.4% 13tPA Stroke Survey R 189 11 15 5.8% 9.5% 34.0% 29.6% 14Indianapolis R 50 11 8.0% 10.0% 16.0% 15Michigan R 37 6 10 10.8% 5.4% 18.9% 16

All Studies 2529 14 5.1% 12.9% 37.1% 19.0%

NINDS (Treated) 312 14 6.4% 17.0% 39.0% 3

Table. Meta-analysis. Summary statistics are weighted by the number of patients in each study. Symptomatic ICH percentages are for bleeding with the first 36 hours or the closes reported time point. Deaths and other outcome measures are at 90 days or the closest time. NINDS trial data are from Part 1 and 2 combined, except for the percentage of very favorable outcomes, which is from Part 2 only.

Glenn D. Graham 2002

ONGOING TRIALSONGOING TRIALSONGOING TRIALSONGOING TRIALS

• Bridging trial: iv followed by iaBridging trial: iv followed by ia

• DEFUSEDEFUSE (US) and(US) and EPITETHEPITETH (AUS)(AUS)

• 3-6h, MRI based3-6h, MRI based

• IST 3 IST 3 (0-6h)(0-6h)

• Placebo within first 3hPlacebo within first 3h• Uncertainity principleUncertainity principle• In-experienced centers - learning In-experienced centers - learning

curvecurve

• Bridging trial: iv followed by iaBridging trial: iv followed by ia

• DEFUSEDEFUSE (US) and(US) and EPITETHEPITETH (AUS)(AUS)

• 3-6h, MRI based3-6h, MRI based

• IST 3 IST 3 (0-6h)(0-6h)

• Placebo within first 3hPlacebo within first 3h• Uncertainity principleUncertainity principle• In-experienced centers - learning In-experienced centers - learning

curvecurve54

EU approval, yes, but EU approval, yes, but conditionalconditional

EU approval, yes, but EU approval, yes, but conditionalconditional

• Actilyse approved within 3 h after stroke, Actilyse approved within 3 h after stroke, but but conditional conditional approvalapproval

• After 3 years After 3 years reconsiderationreconsideration based on: based on:

• Safety monitoring of treated patients Safety monitoring of treated patients ((SITS-MOSTSITS-MOST))

• RCT within 3-4 h interval (RCT within 3-4 h interval (ECASS IIIECASS III))

• Actilyse approved within 3 h after stroke, Actilyse approved within 3 h after stroke, but but conditional conditional approvalapproval

• After 3 years After 3 years reconsiderationreconsideration based on: based on:

• Safety monitoring of treated patients Safety monitoring of treated patients ((SITS-MOSTSITS-MOST))

• RCT within 3-4 h interval (RCT within 3-4 h interval (ECASS IIIECASS III))

Observational study of safety and efficacy within 3 hours of symptom onset in acute ischaemic stroke> 1500 patients per year, 3yearsInternational, multicentre trial100 - 200 centresPrimary safety variables:- symptomatic ICH at 36 hours- mortality at 3 months

Secondary efficacy variables:- Independence for activities of daily living at 3 monthsIn-/exclusion criteria: strictly according to SPC

AIS Patientsuitable for

rt-PA

SITS-MOST

ECASS 3

0-3 hours 3-4 hours

Double-blind, placebo-controlled study in the 3 - 4 h time window after Double-blind, placebo-controlled study

2 400 patients

Study duration: from 1.Q 2003 to 4.Q 2005

Primary endpoint: mRS 0 - 1

Secondary endpoint: Global outcome

In-/exclusion criteria: strictly according to the SPC, except time window

SITS-MOST SITS-MOST means means

SSafeafe I Implementation ofmplementation of TThrombolysis inhrombolysis in S Stroke: The troke: The

MoMonitoring nitoring StStudyudy

www.acutestroke.org

www.acutestroke.org

SITS National SITS National CoordinatorsCoordinatorsSITS National SITS National CoordinatorsCoordinatorsSITS National

Coordinators

approvecentres who applyfor membershipin SITS-MOST

Possible to join also outside Europe

Possible to join also outside Europe

E C A S S IIIE C A S S III

The ThirdThe Third

European CooperativeEuropean Cooperative

Acute Stroke StudyAcute Stroke Study

History History

Most stroke patients do not arrive Most stroke patients do not arrive at hospital within a 3 h time at hospital within a 3 h time windowwindow

EU Health Authorities wanted to EU Health Authorities wanted to extend the time window from 3 to 4 extend the time window from 3 to 4 hourshours

The scientific society wanted to The scientific society wanted to know whether there is benefit know whether there is benefit beyond 3 hoursbeyond 3 hours

ECASS III

ObjectiveObjective

The aim of ECASS III is to confirm The aim of ECASS III is to confirm the superiority of rt-PA over the superiority of rt-PA over placebo for patients with ischemic placebo for patients with ischemic stroke when administered within a stroke when administered within a time window from 3 to 4 hours from time window from 3 to 4 hours from the onset of symptoms the onset of symptoms

ECASS III

Study Design 1Study Design 1

• ECASS III is a double-blind, placebo- ECASS III is a double-blind, placebo- controlled, randomized study to controlled, randomized study to determine the safety and efficacy of determine the safety and efficacy of 0.9mg/kg rt-PA in acute ischemic 0.9mg/kg rt-PA in acute ischemic

stroke stroke when administered within a 3-4 when administered within a 3-4 hour time hour time windowwindow

ECASS III

Study Design 2Study Design 2

• ECASS III will be performed inECASS III will be performed in

- 80 study sites in- 80 study sites in

- 15 European countries - 15 European countries

• Patient recruitment will start in the Patient recruitment will start in the 1st 1st quarter ofquarter of 2003 2003

ECASS III

EndpointsEndpoints

PRIMARY ENDPOINTPRIMARY ENDPOINT

• Modified Rankin Scale 0-1 at day 90 Modified Rankin Scale 0-1 at day 90

• SECONDARY ENDPOINTSSECONDARY ENDPOINTS

• Global outcome (mRS 0-1, Barthel Index Global outcome (mRS 0-1, Barthel Index 100-95, Glasgow Outcome Scale 0-1) at 100-95, Glasgow Outcome Scale 0-1) at day 90day 90

• Modified Rankin Scale 0-1 at day 90 Modified Rankin Scale 0-1 at day 90 stratified by admission NIHSS stratified by admission NIHSS

ECASS III

Sample sizeSample size

• The size of 400 patients per group will The size of 400 patients per group will allow to detect or disapprove a 10% allow to detect or disapprove a 10% difference in the primary endpoint difference in the primary endpoint between the treatment groups (two-between the treatment groups (two-sided alfa = 5% and power probability of sided alfa = 5% and power probability of about 90%) about 90%)

ECASS III

Inclusion CriteriaInclusion Criteria

• Age : 18-80Age : 18-80

• Clinical diagnosis of ischemic stroke Clinical diagnosis of ischemic stroke causing a measurable neurological causing a measurable neurological deficit (NIHSS deficit (NIHSS << 24), no significant 24), no significant improvement improvement

• Treatment possible within a time Treatment possible within a time window from 3 to 4 hourswindow from 3 to 4 hours

• Informed consentInformed consent

ECASS III

Exclusion criteriaExclusion criteria

ClinicalClinical

• Severe stroke (NIHSS >24 on admission)Severe stroke (NIHSS >24 on admission)

• Diabetes and earlier clinical strokeDiabetes and earlier clinical stroke

• Usual thrombolysis exclusion criteria Usual thrombolysis exclusion criteria such as such as trauma, malignancy, pre-trauma, malignancy, pre-

existing handicap, recent existing handicap, recent surgery and surgery and puncture, pregnancy, and others puncture, pregnancy, and others

ECASS III

Exclusion criteriaExclusion criteria

CT-scanCT-scan

• Evidence of ICH on the admission CTEvidence of ICH on the admission CT

ECASS III

Conclusions Conclusions

• ECASS III is not going to be an easy trial ECASS III is not going to be an easy trial but if it is positive the time and effort it but if it is positive the time and effort it takes to perform it is well spenttakes to perform it is well spent

• If the hypothesis that rt-PA is safe and If the hypothesis that rt-PA is safe and effective up to 4 hours, proves to be effective up to 4 hours, proves to be correct, the therapy will be available for a correct, the therapy will be available for a larger European stroke populationlarger European stroke population

ECASS III

CONCLUSIONSCONCLUSIONSCONCLUSIONSCONCLUSIONS• WE HAVE A MAJOR CHALLENGEWE HAVE A MAJOR CHALLENGE

• If we are not able to treat stroke patients If we are not able to treat stroke patients more effectively in the future than we have more effectively in the future than we have done in the past we do not have resources to done in the past we do not have resources to treat all stroke patients properlytreat all stroke patients properly

• Thrombolysis in stroke is safe and effective, Thrombolysis in stroke is safe and effective, evidence-based medicine (EBM)evidence-based medicine (EBM)

• We have now a better treatment for patients We have now a better treatment for patients with acute ischemic stroke than ever with acute ischemic stroke than ever before before

• LET US TAKE THE CHALLENGE !LET US TAKE THE CHALLENGE !

• WE HAVE A MAJOR CHALLENGEWE HAVE A MAJOR CHALLENGE

• If we are not able to treat stroke patients If we are not able to treat stroke patients more effectively in the future than we have more effectively in the future than we have done in the past we do not have resources to done in the past we do not have resources to treat all stroke patients properlytreat all stroke patients properly

• Thrombolysis in stroke is safe and effective, Thrombolysis in stroke is safe and effective, evidence-based medicine (EBM)evidence-based medicine (EBM)

• We have now a better treatment for patients We have now a better treatment for patients with acute ischemic stroke than ever with acute ischemic stroke than ever before before

• LET US TAKE THE CHALLENGE !LET US TAKE THE CHALLENGE !