thrombolytics not effective in treatment of strokes?
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Smash
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Indeed, and those are the things that appear to result in long term favourable outcomes for stroke patients. Not tPA.
The study is a small, non-blinded, single arm, non-patient focussed study, published by the inventors of the device and owners of the company that sell the device, that was still rife with protocol variation, changed tack part way through, and still didn't manage to show any particularly significant outcomes. It's hardly worth the paper it is written on.
True but the site which Dwindlin linked to has physicians who are associated with major neuro centers which did extensive trials on the mechanical devices (including MERCI) as well as different medications which may also have put up the grants for the research.
St. Luke’s Roosevelt Hospital Center
Hymann-Newman Institute of Neurology and Neurosurgery
http://www.vascularcareny.com/
http://rd.springer.com/article/10.1007/s11883-010-0121-8
Mass General
http://neurosurgery.mgh.harvard.edu/
Their research with ongoing studies and published material is definitely a worthwhile read.
Also, just like Circulation is a good AHA journal to read occasionally, so is Stroke.
http://stroke.ahajournals.org/
Not quite. The site I linked is an independently ran site that compiles, organizes, and presents information in the literature. They are all (with the exception of one) EM physicians/residents. And actually TheNNT has nothing on embolectomy vs. tPA, the link is tPA only.
Yes but if you look at the originators of that website you will see their affiliations. These Physicians could not work in their hospitals without knowing something about what the facility offers or is famous for. When a patient comes in with a stroke, the neuro physicians will be consulted by the EM Physicians. EM Physicians are not alone in the management of stroke patients and will have access to other options at large centers as well as the opinions of the Neurologists, Neurosurgeons and Neuroradiologists who all may have their own pet project they are partial to at major teaching hospitals.
The opinions and limitations of tPA have been known for awhile which is why there are other options and so many opinions for the alternatives.
Smash
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I'm not sure what your point is. You linked to a heap of faculty websites, or journals, but no articles per se.
If you have some articles that demonstrate the efficacy of mechanical embolectomy, please share them.
If you have some articles that demonstrate the efficacy of mechanical embolectomy, please share them.
Heap? No. Two major centers which the Physicians from Dwindlin's link are from.
Massachusetts General Hospital (MGH) is in Boston. It is a major teaching hospital with a large neuro center within it.
St. Luke's-Roosevelt Hospital Center is in New York City.
It sometimes helps to know what part of the world or the US researchers or doctors are from to understand why they might be pro or con on something.
I believe EMS is very much like that also. Calfornia does not have a great reputation while NZ and AU have a different outlook on education and certain protocols or guidelines. In the US, East Coast and West Coast medicine have some considerable differences. If you know where the authors of websites or articles are from you can sometimes see where their biases might be.
So don't get yourself all worked up and you don't have to understand or read anything I have written. I am just showing where to look for whatever research and what these two hospitals are well known for. Those who work there may have similar views. With the abundance of research going on, some physicians can pick and choose who they might be partial to. This is no different than when an EMS Medical Director chooses to write protocols based on whatever EBM he or she might be most comfortable with based on the facilities or agencies which have done the most research.
Click on the education, publication and clinical trials taps of the links I posted from the two hospitals. They have both pubished a great deal so don't expect me to post everyone. You can also use a medical search engine to refine your search if you want. I have read a few articles but mostly I have paid attention to the neurologists talking when we do a CCT to their facility. There is alot happening to the patients beyond the ED.
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Smash
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I'm not worked up, I'm just not sure what you are intending by these posts. Do you disagree that thrombolytics are not effective? Or do you propose that thrombolytics with clot removal is better? Or... what?
What individual hospitals are known for has no bearing on what the research is saying about thrombolysis for stroke, so I'm not sure what the relevance is to this thread. I appreciate geographical differences in the practice of medicine, both in and out of hospital (having worked in more than one country myself), however I am reasonably sure that a stroke in Bangkok is the same as a stroke in Frankfurt, so I'm not sure what bearing that has on the evidence for a particular treatment modality.
What individual hospitals are known for has no bearing on what the research is saying about thrombolysis for stroke, so I'm not sure what the relevance is to this thread. I appreciate geographical differences in the practice of medicine, both in and out of hospital (having worked in more than one country myself), however I am reasonably sure that a stroke in Bangkok is the same as a stroke in Frankfurt, so I'm not sure what bearing that has on the evidence for a particular treatment modality.
KellyBracket
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Yeah, a few of us are aware of that issue. The NINDS trial, almost 20 years ago, has been the only positive trial that looked at CVAs treated within 3 hours. ECASS-3 looked at 3-4.5 hours, but had a somewhat different population, and the newly-published IST-3 trial, despite the hype, didn't actually show a benefit.
So, when you point out that I'm criticizing an old trial, and nothing more recent, well... That's the point, really.
I know Huntington Hospital in Pasadena, CA is participating in a study comparing the effectiveness of bat venom vs tpa. Here is a link to info on dspa.
http://mblogs.discovermagazine.com/...spired-by-vampire-bats-enter-phase-ii-trials/
http://mblogs.discovermagazine.com/...spired-by-vampire-bats-enter-phase-ii-trials/
DrParasite
The fire extinguisher is not just for show
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As an uneducated person in this conversation with more educated, may I interject a question?
So if tPA doesn't work, what (prehospitally) should we do for stroke patients in the field? what should ALS be doing? if nothing, should a BLS unit (or a taxi, just like with Trauma) do the stare of life, and transport to the nearest hospital?
(and now totally speaking devil's advocate)
if nothing can be done for stroke victims in the hospital, do they even need to go to the hospital? Kelly Bracket said
So if tPA doesn't work, what (prehospitally) should we do for stroke patients in the field? what should ALS be doing? if nothing, should a BLS unit (or a taxi, just like with Trauma) do the stare of life, and transport to the nearest hospital?
(and now totally speaking devil's advocate)
if nothing can be done for stroke victims in the hospital, do they even need to go to the hospital? Kelly Bracket said
Following that line of thinking, shouldn't we not even transport to the ER (or any specialized stroke center), and maybe have the family just drop the patient off at a nursing home, where they can get the nursing home to handle all the stuff that was just mentioned as saving lives in CVA? After all, if the hospital can't do anything to help them, why even bring them there at all?
tPA is just one treatment. There are several others but getting the patient to the most appropriate neuro center in a timely manner is key. The outcomes are not nearly as bleek as KellyBracket is leading you to believe. If you ever get an opportunity to tour a major neuro ICU as well as a Rehab center, don't pass it up. You will also see nurses in this specialty do much more than just swab the mouths of patients. That actually is a care standard for all patients in an ICU.
The websites posted earlier to Mass General and the hospital in NYC goes into great detail about what can be done in a hospital for neuro patients. I don't know where the other poster got the idea nothing can be done at a hospital for a patient especially with today's technology to bring the neurologist to the bedside even if a hundred miles away.
If you must transport only to the nearest hospital, hopefully they have access to telemedicine connecting them to a neuro center and to a critical care transport team that can continue the care initiated. The neuro physician will assess via phone or telemedicine video and get the correct team in place to begin the necessary interventions once the patient arrives. There has been alot of talk here about the cath lab but the IR for neuro patients is equally impressive.
Of course if the ER physician is close minded and refuses to believe neuro can be helped by any means and any intervention is a waste of time or doesn't keep up with what is going on in medicine, the patient is screwed.
The specialized nursing care in the ICU will consist of medications, multiple drips, a neuro hypothermia protocol that might last for several days rather than just 24 hours such as the cardiac ROSC protocol, invasive drains and monitors placed in the head and all of the other post operative assessments and care.
What's your basis for this statement? Are you saying he's trying to mislead us?
KellyBracket
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My main concern, ironically, is that everybody is so pessimistic about the outcomes in (non-tPA-treated) stroke patients, that they feel compelled to take a risk with untested devices or risky drugs.
Far from portraying a bleak picture, it has been shown that specialized nursing care, in dedicated neuro/stroke ICUs, saves lives. Lytics have never been shown, OTOH, to have an effect on mortality. Rather than suggesting we not treat stroke patients, I suggest that we keep in mind which interventions have actually shown benefit in proper trials.
For example, we have this trial: Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke. They showed a 16% drop in mortality in the first 90 days, "just" with nursing care.
Contrast this against the thrombectomy devices, which continue to be employed despite the lack of good data to show improved neuro outcomes or mortality benefit. One review published last year, Neurothrombectomy Devices for the Treatment of Acute Ischemic Stroke: State of the Evidence, found mixed and "promising" data, but an editorial made it clear that "It is premature to compare different devices until we first establish the clinical benefit of neurothrombectomy over thrombolysis. Until then, expansion of the use of neurothrombectomy is unjustified."
Of course, a large stroke, just like a devastating trauma or a massive MI, is likely to have a bad outcome, often regardless of treatment efforts. But that is no reason to stop looking at the evidence.
Far from portraying a bleak picture, it has been shown that specialized nursing care, in dedicated neuro/stroke ICUs, saves lives. Lytics have never been shown, OTOH, to have an effect on mortality. Rather than suggesting we not treat stroke patients, I suggest that we keep in mind which interventions have actually shown benefit in proper trials.
For example, we have this trial: Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke. They showed a 16% drop in mortality in the first 90 days, "just" with nursing care.
Contrast this against the thrombectomy devices, which continue to be employed despite the lack of good data to show improved neuro outcomes or mortality benefit. One review published last year, Neurothrombectomy Devices for the Treatment of Acute Ischemic Stroke: State of the Evidence, found mixed and "promising" data, but an editorial made it clear that "It is premature to compare different devices until we first establish the clinical benefit of neurothrombectomy over thrombolysis. Until then, expansion of the use of neurothrombectomy is unjustified."
Of course, a large stroke, just like a devastating trauma or a massive MI, is likely to have a bad outcome, often regardless of treatment efforts. But that is no reason to stop looking at the evidence.