tPA: a rural network experience.

To the Editor: We read with considerable interest the report of the Order of St Francis (OSF) Stroke Network in Peoria,1 discussing their early experience promoting the use of intravenous tissue plasminogen activator (IV tPA) in central Illinois. Since 1996 we have been somewhat differently organized in Minnesota for a similar phase IV assessment of this important therapy. Our initial report in 19982 presented 60 patients collected over 14 months, a quantity similar to the current OSF report. It was our judgment then, and our main criticism now of the OSF report, that such a limited number of patients precludes any meaningful statistical analysis of data and conclusions must be viewed with great reservation. Our most recent report3 of 151 patients accumulated over 34 months—now 252 patients over 43 months, as presented at the recent American Stroke Association 25th Annual Stroke Conference—still is limited by marginally adequate numbers. It has, however, provided us with sufficient data to apply multivariate analysis to questions about size, rural/urban location and academic affiliation of treating hospitals, specialty expertise of supervising physicians, pretreatment patient risk factors, accuracy of pretreatment CT interpretation, incidence and predictors of poor outcomes including symptomatic intracerebral hemorrhage (ICH) and ICH-related death. Our steering committee of volunteer stroke neurologists has reviewed CT images on every patient with a poor outcome; we obtained posttreatment CT scans on approximately 70% of patients and so know much about asymptomatic ICH. All CT images, regardless of clinical outcome, have been reviewed by a neuroradiologist blinded to all clinical details. This process has given us confidence that IV tPA in …