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Stroke: Medical Crisis!



The saddest brainstorm

Risks and hazards

Treatment Conundrum

Big hopes, big flops

Clot clout.

    Clots, busted

Ischemic (clot) strokes may be less deadly than strokes caused by broken arteries, but 22 percent of men, and 25 percent of women, still die each year. The approved way to destroy stroke-causing clots is the drug tissue plasminogen activator.

TPA breaks clots by attacking the strands of fiber between the clotting cells, called platelets. Normally, a clot seals the walls of a blood vessel soon after it breaks. Within a half-hour the repair is under way and the body makes TPA to attack the fibers and dissolve the clot.

For several years, artificial TPA has been used to clear clots that cause heart attacks, and over the past five years, the drug has also become the mainstay of stroke treatment -- if patients can receive it within three hours. After that, too many brain cells are dead, and TPA's benefits begin to pale compared to the risk that it will cause dangerous bleeding.

Literally, a deadline
Because doctors can do nothing until a patient arrives, it is crucial to know the stroke warning signs: weakness, especially on one side, or sudden loss of vision or speech. If you recognize these signs, call an ambulance immediately and mention the possibility of stroke!

If patients and emergency medical workers treat a stroke as a medical emergency, and if doctors drop everything -- even the nine iron -- to quickly diagnose ischemic stroke and plug TPA into a vein, the drug can make a real difference. Emergency sign
After a quick diagnosis, the ambulance crew must burn rubber, sirens a-wailing, to a stroke center, if one is available. "Our message is 'Load and go,'" says stroke doctor Wayne Clark of Portland, Ore., where hospitals have designated a few stroke centers at certain hospitals. "There's little to do in the field."

In Portland, and in Houston, ambulances hustle stroke victims to hospitals with stroke teams, where CT scanners can quickly confirm the presence of ischemic stroke. Nationally, an estimated 1 to 2 percent of stroke patients get TPA. In Houston, between 17 and 20 percent of patients get the drug, which is close to the number of patients who reach the ER in time.


Time is brain
All that hustle translates into a radical improvement in health and quality of life, says Robert Felberg, a cerebrovascular fellow at the University of Texas at Houston. While nationally, about 20 percent of ischemic stroke patients return to work and independent living, Felberg says the rate in Houston is 35 to 40 percent.

Although TPA can cause bleeding anywhere in the body, Felberg says experience and good patient screening can control that side effect. In Houston, 3 percent of patients had hemorrhages that made them sicker; compared to 6 to 7 percent of patients in a national TPA trial.

Can't do
Where strokes are not treated as medical emergencies, usage levels can be disturbingly low. Researchers in Cleveland, Ohio, for example, found that only about 1.7 percent of 3,948 stroke patients got the clot-buster
Emergency room entrance(see "Intravenous Tissue-Type..." in the bibliography). TPA-treated patients also died more than three times as often as other stroke patients, perhaps due to a flouting of treatment guidelines.

Today, immediate TPA treatment requires neurologists to drop everything and hustle to the ER. When TPA was first used to bust clots in heart arteries, cardiologists ran the show, but today, ER doctors are opening the spigot on clot-busters.

Can do
A similar shift would be logical in stroke treatment, observes Paul Akins of Mercy Healthcare in Sacramento, Calif. "The emergency room is where the fate of a vast number of stroke patients is largely determined," Akins said while presenting a study comparing 20 patients treated by neurologists to 23 treated by ER physicians.

The ER docs did talk by phone with a neurologist, and the neurologists did act a bit quicker -- getting TPA into patients an average of 97 minutes after the patients reached the hospital, 11 minutes faster than the ER docs (in Houston, incidentally, the "door to drug" goal is 45 minutes). But for both doctor types, 46 percent of the patients recovered enough to go directly home from the hospital. "There was a need to evaluate whether emergency doctors could administer TPA safely and effectively," says Akins. "Our results showed that it could be done."

What about the dark side of drug treatment?


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