Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience

JAMA. 2000 Mar 1;283(9):1151-8. doi: 10.1001/jama.283.9.1151.


Context: Little is known regarding outcomes after intravenous tissue-type plasminogen activator (IV tPA) therapy for acute ischemic stroke outside a trial setting.

Objective: To assess the rate of IV tPA use, the incidence of symptomatic intracerebral hemorrhage (ICH), and in-hospital patient outcomes throughout a large urban community.

Design: Historical prospective cohort study conducted from July 1997 through June 1998.

Setting: Twenty-nine hospitals in the Cleveland, Ohio, metropolitan area.

Patients: A total of 3948 patients admitted to a study hospital with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification code 434 or 436).

Main outcome measures: Rate of IV tPA use and occurrence of symptomatic ICH among patients treated with tPA; proportion of patients receiving tPA whose treatment deviated from national guidelines; in-hospital mortality among patients receiving tPA compared with that among ischemic stroke patients not receiving tPA and with mortality predicted by a model.

Results: Seventy patients (1.8%) admitted with ischemic stroke received IV tPA. Of those, 11 patients (15.7%; 95% confidence interval [CI], 8.1%-26.4%) had a symptomatic ICH (of which 6 were fatal) and 50% (95% CI, 37.8%-62.2%) had deviations from national treatment guidelines. In-hospital mortality was significantly higher among patients treated with tPA (15.7%) compared with patients not receiving tPA (5.1%, P<.001) and compared with the model's prediction (7.9%; P<.006).

Conclusions: A small proportion of patients admitted with acute ischemic stroke in Cleveland received tPA; they experienced a high rate of ICH. Cleveland community experience with tPA for acute ischemic stroke may differ from that reported in clinical trials.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Cerebral Hemorrhage / epidemiology
  • Cerebral Hemorrhage / prevention & control
  • Female
  • Hospital Mortality
  • Humans
  • Infusions, Intravenous
  • Male
  • Middle Aged
  • Ohio
  • Plasminogen Activators / administration & dosage
  • Plasminogen Activators / therapeutic use*
  • Practice Guidelines as Topic
  • Prospective Studies
  • ROC Curve
  • Regression Analysis
  • Statistics, Nonparametric
  • Stroke / drug therapy*
  • Stroke / physiopathology
  • Survival Analysis
  • Thrombolytic Therapy*
  • Tissue Plasminogen Activator / administration & dosage
  • Tissue Plasminogen Activator / therapeutic use*
  • Treatment Outcome


  • Plasminogen Activators
  • Tissue Plasminogen Activator