Thrombolysis is regularly given to patients with DVT or brain infarctions, I wonder if this is always risk-free?

If we have a massive cartoid thrombosis, for instance, would treatment with thrombolysis undermine the structural integrity of the thrombosis, so that it breaks up into large segments which then cause embolims before they dissolve?

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Thrombolytics: Risk vs Reward

The thrombolytics risk vs reward debate isn't going anywhere for a while. It isn’t due to lack of numbers or statistics. The reason that this issue is still debated is all about the reliability of the data.

Stroke is a devastating condition and every clinician wants to do everything in their power to help their patients. Unfortunately, good intentions are not enough, and it is generally our sickest patients in whom we need to be most careful about the delicate balance between doing good and doing harm.

I can’t tell you for sure whether thrombolytics work. Physiologically speaking, they are clearly doing something, as is evidenced by the increase in bleeding.

There is a hint at benefit throughout a number of studies, but that has to be tempered by the various sources of imbalance and bias in this literature.

My guess is that there must be some subgroup of patients who are benefiting to balance out harms in others. Unfortunately, our currently approach is akin to giving thrombolytics to all chest pain patients, or at least to any patient with a positive troponin. In that population, lytics fail. We don’t have an ST elevation equivalent to guide us in stroke.

My biggest concern is that the push to define tPa as the “standard of care” has robbed us of the important research that would have discovered this subgroup.

Bottom Line?

I don’t know. If NINDS was replicated today, I would open the odds between 4:1 and 9:1 against the same results. (In other words, I think there is about a 10-20% chance that if the same protocol was run, we would see the same results). I think we clearly need more research. I think basic philosophy of science and statistical tenants tell us that we must attempt to replicate NINDS. Or maybe this whole debate will simply disappear, as endovascular therapy becomes the new norm. More on that next time…

How tPA Should be Presented to Patients

“There is a treatment we sometimes use for stroke that is supposed to break down the clot causing the stroke. The treatment is controversial, and you will probably hear different things from different doctors. The issue is that out of 13 major trials, only 2 have shown benefit, and both of those trials have some problems, and they were both paid for by the people who make the drug.

There are some risks that we’re certain about: about 1 in 12 patients will have severe bleeding resulting in worse neurologic outcome. Despite that risk, in the best case scenario, about 1 in 10 people given this drug early will have a noticeable improvement in their function after 3 months.

Unfortunately, it isn’t clear how reliable the science has been, and we don’t know which patients have the greatest chance at benefit or harm. The choice to receive this medication remains up to each individual patient.”

Source: https://first10em.com/2017/05/26/thrombolytics-for-stoke/

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