tPA:Give the juice… quickly


By Nicola Garrett

29 May 2018

An international stroke expert has urged neurologists to make sure their stroke services are set up so their patients are able to receive thrombolysis within 30 minutes.

Dr Michael D Hill, a stroke neurologist from the University of Calgary in Canada, told ANZAN 2018 delegates that in a typical large vessel acute ischaemic stroke, 1.9 million neurons, 14 billion synapses and 12 km of myelinated fibers are destroyed every minute.

“The statistics are staggering but they are very helpful in motivating our teams because it’s the new currency… every minute equals millions of neurons… it’s a good way to get people to move their… to move!” he told the room full of chuckling delegates.

Yet there’s something about human nature that states that if we think we have x amount of time we’re more likely to take it, Dr Hill said.

“Parkinson’s Law  – the job expands to fit the time available – is as true in stroke care as it is in economics,” he said.

For example, a trial showed that for every 10 minute delay in ER arrival thrombolysis treatment was 18 minutes faster.

“It’s that issue of ‘thresholding’… if you think you have three hours you’re more likely to take the time where what you should really be doing is treating everybody quickly”.

In order to change this mentality Dr Hill said the target must be revised downward to a 30-minute door-to-needle time.

In Canada, particularly in Alberta, they were working hard to get people treated within this target.

“We’re getting really close, we’re on average running between 30 and 35 minutes for everybody in the whole province. It’s working, but it takes a lot of effort to get this done”.

And the difference in effect size for a door-to-needle time of under 30 minutes was significant, with every five patients treated in this time window meaning one extra person will have an excellent outcome — an NNT of 5, he said.

“The magnitude of the fact is actually quite staggering… I’ll put it to all of you out there treating patients…. It’s almost unethical not to set up your systems so that you can treat people quickly.”

“But it’s not all on you, it takes the whole team to make it happen.  We really need to get people treated under 30 minutes – everybody, not just on average” he added.

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