Daniel M. Lindberg, MD reviewing Mazya MV et al. Neurology 2015 Nov 6

Some guidelines include severe stroke as a relative contraindication for tissue plasminogen activator (tPA) therapy, because of concern that rates of parenchymal hemorrhage will be higher in patients with severe stroke. These researchers used a European observational database of patients treated with tPA for ischemic stroke to compare rates of parenchymal hemorrhage between 868 patients with the most severe stroke (NIH Stroke Scale >25) and nearly 20,000 with more moderate stroke (NIH Stroke Scale 15–25) treated in 793 centers between 2002 and 2013.

Patients with very severe strokes were older, had more comorbidities, and were more likely to have posterior circulation stroke and to present obtunded or comatose. In addition, patients with very severe stroke were more likely than those with more moderate stroke to be treated more than 3 hours after symptom onset (26% vs. 15%). Rates of parenchymal hemorrhage were similar between the two groups (10.7% and 11.0%), as were rates of symptomatic intracerebral hemorrhage (1.4% and 2.5%). While mortality and functional outcomes were worse in those with very severe strokes, the authors concluded that this was a result of stroke severity, rather than a complication of tPA administration.


tPA remains the only approved pharmaceutical treatment for acute ischemic stroke. Relative to the potential benefit of tPA treatment, the risk of parenchymal hemorrhage is low, and, contrary to previous guidance, tPA should be an option for eligible candidates with very severe strokes.


Mazya MV et al. IV thrombolysis in very severe and severe ischemic stroke: Results from the SITS­ISTR Registry. Neurology 2015 Nov 6; [e­pub]. (http://dx.doi.org/10.1212/WNL.0000000000002199 )