Thrombolysis in the treatment of acute stroke: Is there a role for streptokinase when tissue plasminogen activator is not available?

Every year 350,000 people suffer an acute stroke in Pakistan. Treatment of acute stroke has not improved significantly despite the availability of intravenous thrombolysis with tissue plasminogen activator (tPA). The drug is expensive and is offered to a selected few. Streptokinase (SK), a low cost alternative thrombolytic agent, is widely available in Pakistan and is utilized to treat patients with acute coronary syndromes. Streptokinase was tested in acute stroke in the 1980's and found to be ineffective in ischemic stroke. This is likely due to trial design flaws, rather than the drug itself. Factors that may have contributed to poor outcomes include a prolonged treatment window, inclusion of patients with established infarction on CT scan, failure to treat excessive arterial pressures, a fixed dose of streptokinase and concomitant use of antithrombotic medications. Given the lack of therapeutic alternatives we believe that a properly designed trial in appropriate patient population utilizing stricter inclusion criteria, including early treatment with a lower dose of SK is warranted.