tPA for Acute Ischemic Stroke and Its Controversies: A Review

Abstract

Background and Purpose:Although neurologists consider intravenous tissue plasminogen activator (tPA) to be standard of care in the treatment of patients with acute ischemic stroke, its use remains contentious within the broader medical community, and particularly among emergency physicians. Why might this be? We provide a historical context to this ongoing controversy by reviewing how neurologists have conceptualized the acute stroke and its treatment, with the aim of bridging this gap.Methods:Based on historical sources in the Mackie Family History of Neuroscience Collection at the University of Calgary, as well as online resources, we trace the evolution of the concept of the “acute stroke,” which has come to mean a stroke that is potentially treatable with tPA. We frame this conceptualization in relation to historical “building blocks” in anatomy, pathology, and physiology. We then use these building blocks to explain why neurologists understand tPA to be effective and why emergency physicians often do not.Results and Conclusions:Arguments against the use of tPA reiterate 20-year-old concerns about its efficacy and safety. We believe these persistent concerns can be framed as a lack of understanding of the “building blocks” upon which neurologists’ conception of tPA is built. Our view suggests that the way forward to bridge the gap between neurology and other disciplines is not to conduct more trials but to offer a shared conceptualization of the trials already completed and of the intellectual tradition from which they emerged.