Faster Response to Acute Strokes Sought
A federally convened panel of experts Friday recommended that the U.S. health care system design a national blueprint for emergency stroke treatment, saying that acute strokes should be treated with the same urgency as heart attacks and trauma.
Recent research has shown that acute strokes can be successfully treated, meaning that there will be no permanent impairment, but only during a small window of opportunity--as short as three hours--after onset of symptoms.
Just a few hospitals in the country, however, can deliver such care to stroke victims quickly, according to the National Institute of Neurological Disorders and Stroke, which called the meeting.
“We now know we can make a difference earlier but the chain . . . must be in place,” said Dr. Paul E. Pepe, director of emergency services for Allegheny General Hospital in Pittsburgh, adding that such a chain must begin with rapid, accurate recognition of symptoms by patients and families.
“Stroke is a lot more subtle than a gunshot wound to the belly,” Pepe said.
Stroke, the third-leading killer after heart attack and cancer, afflicts about 500,000 Americans annually, and 145,000 die from stroke complications.
In Los Angeles, where an estimated 25,000 people suffer strokes every year, most area hospitals offer clot-buster therapy, and many are participating in clinical trials of new neuroprotective drugs to minimize damage from stroke.
The “brain attack team” at UCLA Medical Center, Santa Monica Hospital and St. John’s Hospital in Santa Monica is considered the region’s most aggressive program and is viewed by many experts as a model for emergency treatment of strokes.
The warning signs of a stroke include a sudden weakness or numbness of the face, arm or leg on one side of the body; sudden dimness or loss of vision, especially in one eye; loss of speech or trouble talking or understanding speech; sudden severe headaches with no known cause and unexplained dizziness, unsteadiness or falls.
Last June, the Food and Drug Administration approved the first effective “clot-busting” treatment for acute ischemic stroke, which occurs when a blood clot lodges in the brain, cutting off circulation. This accounts for about 80% of all stroke victims. The remaining are those who suffer from a burst blood vessel.
The drug tPA or Activase, already widely used to treat heart attacks, was shown to significantly reduce the amount of brain damage when given quickly after the onset of symptoms. It is a natural protein that works by dissolving clots.
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In a major study of the drug reported last year in the New England Journal of Medicine, 50% of stroke victims treated with tPA were able to return to their normal lives, compared to 38% of those who did not receive the drug.
The federally sponsored panel, which brought together experts from the fields of neurology, emergency medical services, health care systems and public education, called for hospitals and emergency personnel to develop timely response systems that will enable stroke patients to be treated with clot-dissolving or similar drugs within one hour of the patient’s arrival at the emergency room.
The recommendations were immediately endorsed by the American Heart Assn., the National Stroke Assn. and other groups.
Dr. Marc R. Mayberg, president of the Congress of Neurological Surgeons, said stroke victims once were considered “moderate to low priority” in emergency rooms.
“Now we know that getting the patient into the hands of competent medical care quickly can make a difference,” he said. “But . . . a coordinated national effort is needed.”
The UCLA program is one of the few in the nation that has such an effort already in place.
The hospital-based stroke team is not only alerted by paramedics transporting stroke victims but by college students hired to work daily in the emergency room for the sole purpose of identifying patients with stroke when they arrive, said Dr. Sidney Starkman, head of UCLA’s comprehensive emergency neurology program.
If the stroke is the result of a clot, the patient then moves to the MRI suite, where new technology allows the team to image the brain area. If fewer than three hours have elapsed since symptoms began, tPA is administered intravenously.
If three to five hours have elapsed since the stroke, radiologists thread a delicate catheter through the patient’s blood vessels and use it to administer tPA directly to the clot. UCLA is one of 10 centers in the country using this technique.
If more than five hours have elapsed, the team may attempt a technique called retrograde transvenous neuroperfusion developed by Dr. John G. Frazee. Frazee’s process requires inserting a thin catheter into the brain on the “backside” of the clot where blood flow is impaired. Using an external pump, oxygenated blood from an artery in the groin is pumped into the area to keep brain cells alive while surgeons determine how to treat the stroke.
Cimons reported from Washington and Maugh from Los Angeles.
