my personal edition > emergency medicine > news


  E-Mail this DGDispatch to a colleague

DGDispatch

Stroke Must Be Managed in Emergency Room Rather Than Intensive Care: Presented at ISICEM

By Jeanne Lenzer

BRUSSELS, BELGIUM -- April 6, 2004 -- New treatments for stroke should encourage doctors to treat stroke as an emergency.

Nihilism about stroke treatment was due to past experiences in which patients with low Glasgow Coma Scores remained in intensive care, intubated, and mechanically ventilated, said Peter J.D. Andrews, MD, Reader in Anaesthesia, Intensive Care & Pain Management, University of Edinburgh Director and Consultant, Intensive Care, Western General Hospital, Edinburgh, Scotland, at the 24^th International Symposium on Intensive Care and Emergency Medicine.

Haemorrhagic stroke accounts for about 10% to 15% of all strokes and are often caused by aneurysms that can rebleed. Detachable coils can now be inserted into the aneurysm to prevent rebleeding. Since 3-D angiography can demonstrate good morphology of an aneurysm, controlled detachable coiling is the "preferred first-line treatment option if the anatomy is okay," said Dr. Andrews.

Acute ischaemic stroke can be treated with tissue plasminogen activator, but in order to obtain benefit, it is critical to get patients to hospital immediately. Toward that end, there are numerous initiatives to alert people to the onset of stroke, such as the "Brain Attack" initiative, and educational campaigns directed at paramedics. "But," said Dr. Andrews, "We also need expert imaging and diagnosis," and there are other management issues that need to be addressed during the acute period."

It is also critical to maintain body temperature, breathing rate and glucose control, as well as electrolyte and magnesium levels, along with managing perfusion pressure, Dr. Andrews said. "Time is brain. There are benefits of more active acute care and there are positive trials of thrombolysis for acute ischaemic stroke, but we need an accurate diagnosis and the treatment is not without risk," he added.

The data from over 2,700 patients treated within 6 hours and reviewed by the Cochrane Collaboration showed a high mortality risk, but a highly significant reduction in death and dependency, Dr. Andrews said. "What is less clear is what the time window is. It's clear [benefit of this treatment] decreases with time; but we can't say where the line of no effect is."

Hopefully, said Dr. Andrews, results of the ongoing 3^rd International Stroke Trial (IST 3) will answer some of these questions. IST 3 will enroll 1,500 patients in the 0 to 3 hour arm and 4,500 patients in the 3 to 6 hours arm, and will evaluate survival and disability at 6 months.


[Presentation title: Stroke As a Medical Emergency.]

E-Mail this DGDispatch to a colleague

To print, use this version