doi: 10.1161/01.STR.0000115527.93618.D3
(Stroke. 2004;35:365.)
© 2004 American Heart Association, Inc.
Advances in Stroke 2003 |
Critical Care and Emergency Medicine Neurology
From Johns Hopkins University Department of Neurology (D.F.H.), Brain Injury Outcomes and Neurosciences Critical Care Divisions, Johns Hopkins Medical Institutions, Baltimore, Md; and the Department of Neurology (W.H.), Ruprecht-Karls-Universität Heidelberg, Germany.
Correspondence to Daniel F. Hanley, MD, Johns Hopkins Medical Institutions, 600 N Wolfe St, Jefferson 1-109, Baltimore, MD 21287. E-mail dhanley{at}jhmi.edu
Key Words: Advances in Stroke • critical care • emergency medical services
Emergency Treatment of Stroke
The past year was highlighted by the implementation of the Paul Coverdell Stroke Registry. This is the first American national effort to assess and facilitate use of recombinant tissue plasminogen activator (rtPA) in the treatment of stroke by promoting quality improvement.1 The registry goal is to reduce the disability associated with stroke. This effort is substantially later than similar efforts in many other developing countries.2 For example, in Europe, the SITS-MOST registry, required by the European authorities in connection with the conditional approval of rtPA, is actively recruiting patients treated within 3 hours after stroke onset will test the effectiveness of regionalized stroke care across >200 sites in 26 countries.3 Recognition that benefits of early, coordinated interventions for the stroke survivor are achievable has been slow in the United States, but overall the evidence from this year’s scientific publications is that barriers to widespread community implementation of effective stroke treatment can be overcome.4
Public and medical system education can change the use of emergency treatment pathways for stroke with >50% of patients reporting in <3 hours in some systems.5,6 Thus, the major barrier to widespread achievement of emergency stroke treatment is acceptance by the medical community. Implementing successful stroke center programs in the United States has now been reported in Cuyahoga County, the Kansas City region, and in a community setting in Maryland.7–9 Organized emergency medicine publicly demonstrated reluctance to endorse regional stroke center utilization or the standard use of rtPA for the indicated.10 The major basis for this disagreement appears to be safety and training. Education has previously been demonstrated to produce effective medical care delivery that overcomes both of these barriers. Thus, it can only be hoped that these same associations will commit to employing the evidence to improve care.4,11 Reports this year demonstrated that multiple communities worldwide are capable of delivering the efficacy promised by the results of the NINDS trial. These authors hope that reason triumphs and the American community can also benefit from more complete access to emergency stroke treatment.
High rates of intravenous rtPA treatment (10% to 18%) previously thought to be obtainable only in clinical studies have been demonstrated. Data demonstrating the ability of emergency medical services personnel to identify stroke reproducibly compared with physicians. Evaluation of the emergency transport time to initiate neuroprotection demonstrates the potential to shorten time to first treatment by over an hour.12 The possibility of initiating brain protection in the field is now achievable, only the useful neuroprotective agent is still missing. This finding mirrors parallel work in acute myocardial infarction, which demonstrates the safety of in the field implementation of established emergency department treatment routines.13,14 Both the path to improved care and the potential for further as yet unrealized public benefits are now very clear.
Intracerebral Hemorrhage
Intracerebral hemorrhage (ICH) remains the most frequent stroke emergency with the highest mortality.15 The first-ever industry-sponsored intervention in ICH, the Novo-7 trial, in which recombinant factor 7 is given to reduce the risk of early hemorrhage growth, is under way as a safety trial, bringing this disease entity more into the center of stroke research.16 This year a MRI study of human perihematomal tissue demonstrated the absence of a major role for ischemia in the early pathogenesis of this disease.17 This study again focuses the efforts of human investigators on clot reduction to minimize local effects of blood and blood products on brain tissue. The study also opens the opportunity for early aggressive blood pressure reduction as a therapeutic intervention. Despite such pathophysiologic indications, equipoise exists with respect to evidence for surgical intervention. This can be seen in recent scientific debate18–20 and from the direct measurements of surgical decision making,21 where a wide range of surgical practices suggests substantial uncertainty about treatment exists. A large trial of early craniotomy, STICH, has been completed. This trial was based on the "uncertainty principle" in which patients for whom the surgeon was uncertain what course to pursue were randomized to early surgical or medical treatment. The trial proposes a novel set of dichotomized outcomes based on change from severity of illness at time of presentation.22 The results will be available in early 2004. A smaller trial in the Netherlands demonstrated the safety of minimally invasive surgery plus urokinase assisted clot lysis. This particular protocol produced a 17% reduction in clot size over medical treatment at 1 week, but did not achieve large, early reductions in hematoma volume.23 Highly selected convenience samples of ICH patients have produced much more impressive reductions in clot size, ie, approximately 90% reduction.24 Thus, the idea that amelioration of the major severity of illness factor (clot volume) can lead to improved mortality or function remains unproven, but also not fully tested. This year’s studies should provide solid basis on which to plan and execute more vigorous collection of evidence regarding the value of clot size reduction: either pro or con.20 What remains clear is that translation of surgical animal models to the human situation has potential for injury reduction.
Intensive Care of Stroke
The malignant MCA infarct syndrome produces rapid onset of dependency. A prospective study of cranial decompression for this injury recently started in Europe. A recent PET study demonstrated deterioration was associated with infarct size but that tissue monitoring of glutamate, ICP, and tissue oxygen tension identified abnormalities too late in the course of deterioration.25 Findings from a 5-center study of timing of deterioration confirmed the rapid onset of this syndrome during the initial 48 hours after stroke in North American hospitals.26 Pneumonia can also complicate large and small strokes. A prospective study demonstrated worse outcomes for the patient whose stroke is complicated by pneumonia.27 Leaving this complication as a possible target for improving stroke outcome. A similar ICU-based evaluation of outcome for ventilated ICH patients suggests that independent functional outcome at 2 years after a bleeding event can be achieved in about half of the survivors.28 This suggests that late assessment of outcomes in ICH may be of particular importance.
Management of blood pressure during stroke is becoming a target for intervention in both ICH and ischemic stroke. Subpopulations of patients that benefit from a particular strategy are now being identified. These include patients with bilateral high-grade stenosis in ischemic stroke29 as well as patients with intraventricular extension of hemorrhage in ICH.30
Footnotes
The opinions expressed in this editorial are not necessarily those of the editors or of the American Stroke Association.
Received December 9, 2003; accepted December 12, 2003.
References
1. Wattigney W, Croft J, Mensah G, Alberts M, Shephard T, Gorelick P, Nilasena D, Hess D, Walker M, Hanley DJ, et al, Registry PCNAS. Establishing data elements for the Paul Coverdell National Acute Stroke Registry, I: proceedings of an expert panel. Stroke. 2003; 34: 151–156.
2. Hill M, Buchan A. Methodology for the Canadian activase for stroke effectiveness study (cases). Can J Neurol Sci. 2001; 28: 232–238.[Medline] [Order article via Infotrieve]
3. Wahlgren N. Sits-most trial; 2003. Available at www.acutestroke.org.
4. Marler J, Goldstein L. Medicine: stroke: tpa and the clinic. Science. 2003; 301: 1677.
5. Steiner M, Brainin M, Stroke Registry for Acute Stroke Units. The quality of acute stroke units on a nation-wide level: the Austrian Stroke Registry for Acute Stroke Units. Eur J Neurol. 2003; 10: 353–360.[CrossRef][Medline] [Order article via Infotrieve]
6. Woimant F, De Broucher T, Vassel P. Management of stroke in France: results of national surveys. Rev Neurol (Paris). 2003; 159: 543–551.[Medline] [Order article via Infotrieve]
7. Rymer M, Thurtchley D, Summers D, Team ABaSIS. Expanded modes of tissue plasminogen activator delivery in a comprehensive stroke center increases regional acute stroke interventions. Stroke. 2003; 34: 58–60.
8. Katzan I, Graber T, Furlan A, Sundararajan S, Sila C, Houser G, Landis D, Stroke CCO. Cuyahoga County Operation Stroke speed of emergency department evaluation and compliance with National Institutes of Neurological Disorders and Stroke time targets. Stroke. 2003; 34: 994–998.
9. Lattimore S, Chalela J, Davis L, DeGraba T, Ezzeddine M, Haymore J, Nyquist P, Baird A, Hallenbeck J, Warach S, Center NSHS. Impact of establishing a primary stroke center ata community hospital on the use of thrombolytic therapy: the NINDS suburban hospital stroke center experience. Stroke. 2003; 34: 55–57.
10. Adams J, Chisholm C. The society for academic emergency medicine position on optimizing care of the stroke patient. Acad Emerg Med. 2003; 10: 805.[CrossRef][Medline] [Order article via Infotrieve]
11. Mitka M. Tensions remain over tpa for stroke. JAMA. 2003; 289: 1363–1364.
12. Crocco T, Gullett T, Davis S, Flores N, Sauerbeck L, Jauch E, Threlkeld B, Pio B, Ottaway M, Pancioli A, Chenier T. Feasibility of neuroprotective agent administration by prehospital personnel in an urban setting. Stroke. 2003; 34: 1918–1922.
13. Svensson l T, Nordlander R, Wahlin M, Zedigh C, Herlitz J. Implementation of prehospital thrombolysis in Sweden: components of delay until delivery of treatment and examination of treatment feasibility. Int J Cardiol. 2003; 88: 247–256.[CrossRef][Medline] [Order article via Infotrieve]
14. Lamfers E, Schut A, Hooghoudt T, Hertzberger D, Boersma E, Simoons M, Verheugt F. Prehospital thrombolysis with reteplase: the Nijmegen/Rotterdam Study. Am Heart J. 2003; 146: 479–483.[CrossRef][Medline] [Order article via Infotrieve]
15. Hemphill J III, Bonovich D, Besmertis L, Manley G, Johnston S. The ICH score: a simple, reliable grading for intracerebral hemorrhage. Stroke. 2001; 32: 891–897.
16. Mayer S. Ultra-early hemostatic therapy for intracerebral hemorrhage. Stroke. 2003; 34: 224–229.
17. Schellinger P, Fiebach J, Hoffmann K, Becker K, Orakcioglu B, Kollmar R, Juttler E, Schramm P, Schwab S, Sartor K, Hacke W. Stroke MRI in intracerebral hemorrhage: is there a perihemorrhagic penumbra? Stroke. 2003; 34: 1674–1680.
18. Minematsu K. Evacuation of intracerebral hematoma is likely to be beneficial. Stroke. 2003; 34: 1567–1568.
19. Hankey G. Evacuation of intracerebral hematoma is likely to be beneficial—against. Stroke. 2003; 34: 1568–1569.
20. Donnan G, Davis S. Surgery for intracerebral hemorrhage: an evidence-poor zone. Stroke. 2003; 34: 1569–1570.
21. Gregson B, Mendelow A. International variations in surgical practice for spontaneous intracerebral hemorrhage. Stroke. 2003; 34: 2593–2598.
22. Mendelow A, Teasdale G, Barer D, Fernandes H, Murray G, Gregson B. Outcome assignment in the international surgical trial of intracerebral hemorrhage. Acta Neurochir. 2003; 145: 679–681.
23. Teenstra O, Evers S, Lodder J, Leffers P, Franke C, Blaauw G. Stereotactic treatment of intracerebral hematoma by means of a plasminogen activator: a multicenter randomized controlled trial. (sichpa). Stroke. 2003; 34: 968–974.
24. Marquardt G, Wolff R, Sager A, Janzen R, Seifert V. Subacute sterotactic aspiration of haematomas within the basal ganglia reduces occurrence of complications in the course of haemorrhagic stroke in non-comatose patients. Cerebrovasc Dis. 2003; 14: 252–257.
25. Dohmen C, Bosche B, Graf R, Staub F, Kracht L, Sobesky J, Neveling M, Brinker G, Heiss W. Prediction of malignant course in MCA infarction by pet and microdialysis. Stroke. 2003; 34: 2152–2158.
26. Qureshi A, Suarez J, Yahia A, Mohammad Y, Uzun G, Suri F, Zaidat O, Ayata C, Ali A, Wityk R. Timing of neurologic deterioration in massive middle cerebral artery infarction: a multicenter review. Crit Care Med. 2003; 31: 272–277.[CrossRef][Medline] [Order article via Infotrieve]
27. Hilker R, Poetter C, Findeisen N, Sobesky J, Jacobs A, Neveling M, Heiss W. Nosocomial pneumonia after acute stroke: implications for neurological intensive care medicine. Stroke. 2003; 34: 975–981.
28. Roch A, Michelet P, Jullien A, Thirion X, Bregeon F, Papazian L, Roche P, Pellet W, Auffray J. Long-term outcome in intensive care unit survivors after mechanical ventilation for intracerebral hemorrhage. Crit Care Med. 2003; 31: 2651–2656.[CrossRef][Medline] [Order article via Infotrieve]
29. Rothwell P, Howard X, Spence J. Carotid endarterectomy trialists’ collaboration: relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease. Stroke. 2003; 34: 2583–2592.
30. Hamani C, Zanetti M, Pinto F, Andrade A, Ciquini OJ, Marino RJ. Intraventricular pressure monitoring in patients with thalamic and ganglionic hemorrhage. Arq Neuropsiquiatr. 2003; 61: 376–380.[Medline] [Order article via Infotrieve]
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