Thrombolytic therapy in acute stroke - Neurologists, get off your hands!

I was privileged to have been one of the original principal investigators in the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group(1) (NINDS rt-PA) and a coauthor of the seminal publication of the results. This study directly led to the Food and Drug Administration's approval of the thrombolytic agent, tissue-type plasminogen activator (t-PA), on June 18, 1996, as the first and, thus far, only accepted therapy specifically directed at acute ischemic stroke. As such, during the last year, I have been an invited lecturer on this treatment at a variety of medical centers, large and small. I am writing to convey my impressions of the lack of enthusiasm for this therapy exhibited by neurologists at places where I have spoken. Rather than embrace, or at least acknowledge, this as the first step in the treatment of neurology's most common serious and debilitating disease (Alzheimer disease excepted), it often has been met with skepticism, criticism, and denial, with discussions centered around why t-PA cannot or should not be used, rather than how it could be used. Such negativism is now evident in the neurological literature in an article with the unambiguous tide: "Tissue-type Plasminogen Activator Should Not Be Used in Acute Ischemic Stroke."(2) In addition, a member of the steering committee of the Multicenter Acute Stroke Trial-Europe, which evaluated another thrombolytic agent, streptokinase, has opined that because trials of streptokinase were aborted because of excessive rates of intracerebral hemorrhage, all such agents, including t-PA, should be studied further before widespread deployment.(3) Two issues are paramount: should t-PA be used to treat acute ischemic stroke, and, if so, what do neurologists have to offer as treating physicians?