TPA or TIA?: New developments in intravenous rt-PA therapy and the management of transient ischemic attack (TIA)

Abstract

The current status and new development of intravenous rt-PA therapy and management of transient ischemic attack (TIA) were systematically reviewed. Recently, many clinical and registered studies have been reported from Japan, which indicated that the efficacy and safety of intravenous rt-PA therapy using a 0.6 mg/kg dose of alteplase were almost comparable with those reported in the USA and Europe where 0.9 mg/kg dosage of alteplase is standard. The problems which now confront us are expanding the therapeutic time window from 3 hours to 4.5 hours, and a comprehensive comparison of outcomes between the two dosing regimens, 0.6 vs. 0.9 mg/kg. We discussed expanding the therapeutic time window using sophisticated imaging protocols and the clinical implications of new rt-PA agents, sonothrombolysis and intravascular devices for thrombectomy. The concept of TIA has dramatically changed in this decade. TIA patients often have acute ischemic lesions which can be visualized only with diffusion-weighted imaging (DWI), and more frequently have ischemic events soon after the initial TIA episode, within 24 hours or a couple of days, much sooner than previously believed. High risk profiles are more easily indentified and timely and appropriate therapeutic interventions with risk controls, antiplatelet or anticoagulant agents, carotid endarterectomy or carotid stenting can avoid future catastrophic ischemic events in patients with acute TIA or more appropriately 'acute cerebrovascular syndrome (ACVS)'.With support from the MHLW our TIA research team is now carrying out clinical studies to establish management strategies for Japanese TIA patients.