IMS-3, SYNTHESIS, and MR RESCUE: No Disaster, but Down to Earth

Excerpt

After an infusion of recombinant tissue plasminogen activator (rt-PA), the proportions of stroke patients without disability (modified Rankin score (mRS): < 2) varied in positive randomized trials between 39 % (NINDS 2) and 52 % (ECASS 3) [1, 2]. This success in ischemic stroke treatment was impressive and is now guiding stroke management since almost 20 years. Intravenous (IV) rt-PA became the Holy Grail of stroke treatment, and any increase in the proportion of patients being treated with rt-PA is regarded a success. It is widely ignored that the absolute risk reduction for death and disability was 13 % (NINDS 2 with an imbalance at baseline favoring rt-PA) and 7 % (ECASS 3) only. Other rt-PA trials did not show a significant effect. Moreover, a combined analysis of all major randomized trials with IV rt-PA showed the disappearance of any beneficial effect within 6 h of stroke onset [3]. Today, stroke physicians treat less than 10 % of their patients with IV rt-PA following international guidelines. Among these happy patients, only few (maximum 13 %) benefit from this treatment. In the real world, IV rt-PA treatment thus reduces disability and death in less than 1 % of an ischemic stroke population. …