stroke article from the NY Times
Many hospitals say they cannot afford to have neurologists on call to diagnose strokes, and cannot afford to have M.R.I. scanners, the most accurate way to diagnose strokes, for the emergency room.
most hospitals have perfusion CT which can give the same diagnosis. As far as a neurologist on call they could transmit the image over the internet to a neurologist at another hospital. The reading of the image doesn't have to be in the same hospital.
Although tPA was shown in 1996 to save lives and prevent brain damage, and although the drug could help half of all stroke patients, only 3 percent to 4 percent receive it. Most patients, denying or failing to appreciate their symptoms, wait too long to seek help — tPA must be given within three hours. And even when patients call 911 promptly, most hospitals, often uncertain about stroke diagnoses, do not provide the drug.
Demoteplase is being studied for up to nine hours after the stroke but time isn't as important as penumbra. If someone has a penumbra 15 hours after the stroke the drug could still be used. TPA actually causes neurotoxicty which is why it is acutally harmful beyond 3 hours and causes hemmorhage.
The drug had a serious side effect — it could cause potentially life-threatening bleeding in the brain in about 6 percent of patients. But the clinical trial demonstrated that the drug’s benefits outweighed its risks.
That 6 percent is only in the first 3 hours. If the drug is given later the percent goes up
There is a way to diagnose strokes more accurately — with a diffusion M.R.I., a type of scan that shows water moving in the brain. During a stroke, the flow of water slows to a crawl as dead and dying cells swell. In one recent study, diffusion M.R.I. scans found five times as many strokes as CT scans, with twice the accuracy. A diffusion M.R.I. “answers the question 95 percent of the time," Dr. Sorensen said.
this probably has more to do with the readers of the scans than the scans themselves. this is very sad if the scan readers do such a poor job. Maybe they were regular CT scans without the proper imaging software. It is hard to tell because the article doesn't go into why this happens and what could be done to correct it.
It is simply not practical to demand the scans at every hospital or even every stroke center, said Dr. Edward C. Jauch, an emergency medicine doctor at the University of Cincinnati and a member of the Greater Cincinnati/Northern Kentucky Stroke Team.
“If you made M.R.I. the standard of care before giving tPA, most centers would not be able to comply,” Dr. Jauch said. And if it takes more time to get a scan — as it often does — it might be better to forgo it and give tPA immediately if the patient’s symptoms seem unambiguous.
This is true because of the 3 hour window and most people will not be helped by the MRI diagnosis. Once the 3 hour window is increased to 9 hours or more the excuse about not having an MRI should go away. The difference would be people dying or living in a wheelchair for 30 or 40 years that otherwise would have been able to care for themselves.
It has still not been shown, though, that M.R.I. scans actually improve outcomes. It might depend on the circumstances and the hospital, said Dr. Walter J. Koroshetz, deputy director of the National Institute of Neurological Disorders and Stroke.
But some who use M.R.I. scans, and who have studied them in research, say the system has to change. They say enough is known about the scans to advocate having them at every major medical center that will treat stroke patients.
“All these problems could be solved if there was a will to do it,” Dr. Sorensen said. In his opinion, it comes down to old and outdated assumptions that there is not much to be done for a stroke, to financial considerations and to a medical system that resists change. But the most significant barriers, he said, are financial.
the biggest thing that needs to be changed is increasing the window passed 3 hours
When she arrived, Dr. Grotta asked if she was sure she wanted the drug. Did she want to risk bleeding in the brain? Dr. Fite did not hesitate. The stroke, she said, “was just so devastating that I would rather die of a hemorrhage in the brain than be left completely paralyzed in my right side.”
“In my horrible voice, I said, ‘Yes, I want the tPA,’ ” Dr. Fite said.
Within 10 to 15 minutes, the drug started to dissolve the clot.
“I had weird spasms as nerves started to work again,” Dr. Fite said. “An arm would draw up real quick, a leg would tighten up. It hurt so bad I was crying because of the pain. But it was movement, and I knew something was going on.”
She was lucky because she was a doctor and knew where to have the ambulance bring her. She was treated within 3 hours. Aside from the reduction of neurotoxicity of Desmoteplase vs. TPA the other advantage of Desmoteplase is it is 150 to 200 times more specific to fibrin than TPA. This allows less drug to be used causing less side effects.
We will know June 1st whether it worked in the phase 3 trial the way it worked in the earlier trials.
