Early Thrombolytic Treatment Of Acute Stroke:
The Importance Of Protocols For Patient And Physician Education by Jonathan Moray, M.D..
Until recently, the treatment of ischemic stroke has concentrated on the prevention
of further brain insult and rehabilitation. In December 1995, the effectiveness of
Tissue Plasminogen Activator (TPA) in the treatment of acute ischemic stroke was
documented by a multicenter study published in the New England Journal of Medicine.
For the first time, it was shown that prompt treatment after initiation of brain
ischemia could reverse neurologic deficits, presumably by re-establishing blood flow
through the stenotic or occluded artery.
Patient Recognition Of Symptoms
The key factor in this study was the initiation of treatment within three hours from
the onset of symptoms. This requires the patient to recognize the symptoms of a stroke
and promptly seek care at the closest emergency ward. Equally important, there must
be recognition by emergency ward staff of the acute stroke and the prompt work-up that
is required for initiation of TPA therapy.
The Need For Emergency Dept. Protocols
To address these concerns, we have drafted a protocol for emergency ward and
hospital staff for Lowell area hospitals. The protocol emphasizes the need to initiate
treatment within three hours, as studies have shown thrombolysis therapy to be
ineffective in acute ischemic stroke treated after this time frame. Also important is
the need to exclude intracranial hemorrhage, other potential bleeding complications,
and the patient�s recent use of anticoagulants. Our protocol calls for discussion of
risks of the therapy, including brain hemorrhage, which was fatal in 3% of the study
population. Consultation with a neurologist and discussion with both patient and family
is strongly advised. It is clear that this new treatment is not for all stroke victims.
Prompt And Well-Coordinated Care Is Critical For TPA Benefits
Recent studies from Europe show that patients are not getting to the emergency wards
fast enough for appropriate initiation of TPA therapy. Much of this delay is attributed
to a lack of education of the signs of a stroke. To this end, we now emphasize to our
patients the important signs of stroke and the need for prompt evaluation. Through a
multifaceted approach emphasizing patient education on the signs of stroke, physician
education on the appropriate uses of TPA, and the development of protocols with
emergency departments, thrombolytic therapy can have a positive impact on a significant
number of stroke patients.
Disclaimer: The information and references contained
herein are intended solely for the information.
It should not be used for treatment purposes, but rather for
discussion with the patient's own physician.
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