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Editorial
Stroke care: the way forward
  1. T W J Watson,
  2. J E Simon,
  3. A M Buchan
  1. University of Calgary
  1. For correspondence:
 T W J Watson; 
 watsont{at}ucalgary.ca

https://doi.org/10.1136/jnnp.74.4.411

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    “Nothing will ever be attempted if all possible objections must first be overcome” (Samuel Johnson)

    The development of coronary care units, cardiac rehabilitation programmes, and thrombolysis revolutionised the management of acute myocardial infarction. Similarly, the development of stroke wards and stroke teams, thrombolysis, and aggressive early rehabilitation have revolutionised stroke care. Unfortunately acceptance and translation of these concepts into clinical practice has been slow. It is imperative that resources are committed to making this new standard of stroke care widely available.

    THE EVIDENCE FOR THROMBOLYSIS

    In 1995 the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA stroke study demonstrated the efficacy of recombinant tissue type plasminogen activator (rt-PA) for the treatment of acute ischaemic stroke (AIS) when administered within three hours of symptom onset.1 This randomised controlled trial of 624 patients reported a 13% absolute increase in favourable outcome at three months (defined as a modified Rankin Scale score (mRS) 0–1). The number of patients needed to treat (NNT) to result in one additional favourable outcome over placebo was seven. rt-PA was associated with an increased absolute risk of symptomatic intracerebral haemorrhage (SICH) (6% v 1% for placebo) but there was no significant increase in mortality. Intravenous rt-PA was approved for use in stroke by the Food and Drug Administration in the United States the following year. In 1999 the Therapeutics Product Programme in Canada provisionally approved the use of rt-PA on the condition that a registry of treated cases was maintained.2 This was the first licensed treatment for AIS and was embraced with enthusiastic optimism by a number of stroke centres, particularly those who had direct experience with rt-PA in the NINDS trial. In September 2002 the European Agency for the Evaluation of Medicinal Products licensed rt-PA on the proviso that a …

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