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The Standard Treatment with Alteplase to Reverse Stroke (STARS) Study

Gregory W. Albers, MD; Vernice E. Bates, MD; Wayne M. Clark, MD; Rodney Bell, MD; Piero Verro, MD; Scott A. Hamilton, PhD

JAMA. 2000;283:1145-1150.

Context  Tissue-type plasminogen activator (tPA) is the only therapy for acute ischemic stroke approved by the Food and Drug Administration.

Objective  To assess the safety profile and to document clinical outcomes and adverse events in patients treated with intravenous tPA for acute stroke in clinical practice.

Design and Setting  Prospective, multicenter study of consecutive patients enrolled between February 1997 and December 1998 at 57 medical centers in the United States (24 academic and 33 community).

Intervention  Intravenous tPA (recombinant alteplase).

Patients  Three hundred eighty-nine patients with a mean age of 69 years (range, 28-100 years); 55% were men.

Main Outcome Measures  Time intervals between stroke symptom onset, hospital arrival, and treatment with tPA; pretreatment computed tomographic scan results, intracerebral hemorrhage, and major systemic bleeding. The modified Rankin Scale score was used to assess clinical outcomes at 30 days.

Results  Median time from stroke onset to treatment was 2 hours 44 minutes, and the median baseline National Institutes of Health Stroke Scale score was 13. The 30-day mortality rate was 13%. At 30 days after treatment, 35% of patients had very favorable outcomes (modified Rankin score, 0-1) and 43% were functionally independent (modified Rankin score, 0-2). Thirteen patients (3.3%) experienced symptomatic intracerebral hemorrhage, including 7 who died. Twenty-eight patients (8.2%) had asymptomatic intracerebral hemorrhage within 3 days of treatment with tPA. Protocol violations were reported for 127 patients (32.6%), and included treatment with tPA more than 3 hours after symptom onset in 13.4%, treatment with anticoagulants within 24 hours of tPA administration in 9.3%, and tPA administration despite systolic blood pressure exceeding 185 mm Hg in 6.7%. A multivariate analysis found predictors of favorable outcome to be a less severe baseline National Institutes of Health Stroke Scale score, absence of specific abnormalities (effacement or hypodensity of >33% of the middle cerebral artery territory or a hyperdense middle cerebral artery) on the baseline computed tomographic scan, an age of 85 years or younger, and a lower mean arterial pressure at baseline.

Conclusions  This study, conducted at multiple institutions throughout the United States, suggests that favorable clinical outcomes and low rates of symptomatic intracerebral hemorrhage can be achieved using tPA for stroke treatment.

Author Affiliations: Stanford Stroke Center, Stanford University Medical Center, Palo Alto, Calif (Dr Albers); Dent Neurological Institute, Millard Fillmore Hospital, Buffalo, NY (Dr Bates); Oregon Stroke Center, Oregon Health Sciences Center, Portland, (Dr Clark); Thomas Jefferson University, Philadelphia, Pa (Dr Bell); Seton Hall University, Edison, NJ (Dr Verro); and Genentech Inc, San Francisco, Calif (Dr Hamilton).

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