September 24, 2008
Not a Moment to Lose in Therapy for Acute Stroke
In an editorial response to a report in the September 25 issue of The New England Journal of Medicine on the efficacy of intravenous thrombolysis treatment in the hours after acute ischemic stroke, Patrick Lyden, M.D., professor of neurosciences and director of the UC San Diego Stroke Center, cautions that the study should not be interpreted to mean that such therapy can be withheld for hours or even minutes.
“The risk of withholding such treatment from patients with acute stroke greatly exceeds the risk of giving it,” said Lyden. “The potential for reversing the disabling side effects of stroke declines with every passing minute.”
The study, (“Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke”) by Werner Hacke, M.D. et al, reports the findings from the European Cooperative Acute Stroke Study III (ECASS III).
The design of this study closely mirrored that of the original National Institute of Neurological Disorders and Stroke (NINDS) trial of recombinant tissue plasminogen activator (rt-PA) for acute stroke, a pivotal trial that Lyden helped lead that showed the first proven therapy for stroke. The important exception in the ECASS III trial is that the window of therapy was expanded to a period of three to four and a half hours, compared to under three hours in the NINDS trial.
According to Lyden, the very real peril of the BCASS III data is that some may take a slower approach to treating acute stroke.
“Nothing could be more wrong,” Lyden states in the editorial. “As we look back on the past decade of thrombolytic therapy for stroke, it is very clear that our focus must remain on the door-to-needle time. Every minute matters during a stroke.”
The UCSD Stroke Team is available 24 hours a day, seven days a week, at the UC San Diego Medical Center. Immediate diagnosis of a potential stroke can be made to determine the appropriateness of tPA therapy, approved in 1996 by the Food and Drug Administration for the treatment of ischemic stroke, which occurs in about 70 to 80 percent of strokes when a blood clot interrupts blood supply to the brain.
Lyden and colleagues at the UC San Diego Medical Center recently completed a first-of-its-kind study of its telemedicine program, which allows the stroke experts real-time visual and audio access to patients and their medical team at remote sites – linking the physicians across long distances to a patient’s bedside via computer, using highly sophisticated video, audio and Internet technology to evaluate the patient. The “STRokE DOC” (Stroke Team Remote Evaluation using a Digital Observation Camera) system was proven to enable the consulting physicians to help the local medical team make appropriate treatment decisions, and better decisions than telephone consultations, when evaluating stroke patients across distant sites. The study was published online in Lancet Neurology on August 3, 2008.
Lyden serves as a regular reviewer for journals such as Neurology, Stroke, and the Journal of Stroke and Cerebrovascular Diseases. Additionally, he serves as an ad hoc reviewer for Archives of Neurology and Experimental Neurology. He is a member of the editorial board of the Journal of Stroke and Cerebrovascular Diseases, a charter member of the editorial board of the International Journal of Stroke, and editor the book Thrombolytic Therapy for Acute Stroke.
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