Published online before print May 10, 2007, doi: 10.1161/STROKEAHA.107.482083
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(Stroke. 2007;38:e30.)
© 2007 American Heart Association, Inc.
Letters to the Editor |
Response to Letter by Vatankhah et al
Emergency Neurology Services, Department of Neurology, and Program of Molecular Neurology, Biomedicum Helsinki, University of Helsinki, Helsinki, Finland
Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
Response:
Vatankhah et al report an important modification of their treatment strategy in managing acute basilar artery occlusion (BAO) patients. While we collected data from case series of BAO patients treated with thrombolysis in hospitals equipped with acute stroke management, either invasively or noninvasively,1 they extend the issue into yet another dimension: to hospitals not equipped with full acute stroke service. They propose telemedical delivery of stroke expertise to community hospitals, for which they and other groups have reported encouraging results.2,3,4 This technique does not pertain to BAO only, but to stroke and thrombolysis for stroke in general. Obviously, the organization of acute stroke services varies from country to country. Relatively little information is available of the delays related to the initial admission of BAO patients to a community hospital and their subsequent transfer to a stroke center.5 In areas and countries where acute stroke services cannot be centralized because of long distances, telemedical networks provide a promising alternative to establish correct diagnosis and initial treatment on-site. Obviously, time is brain also in the posterior circulation, and every effort should be made to recanalize the occluded basilar artery once the situation has been correctly diagnosed. The diagnosis of BAO can be tricky and in most instances requires some form of vascular imaging, which cannot be replaced by teleconsultation. However, IV thrombolysis (IVT) offers a possibility for early recanalization of suspected BAO in hospitals not equipped with full acute stroke service and interventional neuroradiology. At least in densely populated areas with reasonably short distances stroke services should be well-coordinated with emergency medical systems so that candidates for thrombolysis are transferred directly to well-equipped stroke centers, thus minimizing the number of patients seeking evaluation in community hospitals.
Although a "bridging" approach for IVT–intra-arterial thrombolysis (IAT) has been tested6,7 and suggested also for therapy of BAO,8 its safety remains to be established. In the anterior circulation, pilot studies comparing the IVT-IAT with placebo-IAT have shown the feasibility but hinted increased risk of fatal outcomes.6 Before we widely adopt the telemedical management and thus also the IVT-IAT approach to BAO and stroke in general we should perhaps first have a look at the heart and acquire more data in stroke. In ST-segment-elevation myocardial infarction (STEMI), percutaneous coronary intervention after interhospital transportation resulted in lower mortality and adverse events compared with on-site thrombolysis.9 In STEMI, thrombolysis and antithrombotic therapy followed by percutaneous intervention (=facilitated percutaneous intervention) offers no benefit over primary percutaneous intervention.10 Facilitated percutaneous intervention regimens including thrombolysis resulted in even increased rates of death, bleeding and stroke and should be avoided.10 IAT or mechanical recanalization for stroke treatment is not directly comparable to percutaneous intervention in STEMI, but common to both is no or at most a partial systemic thrombolytic effect. It may therefore well turn out that IVT or IAT alone will be more superior for treatment of BAO than the bridging approach suggested by Vatankhah and colleagues. In addition, when it comes to rapid long-distance interhospital transfer to IAT right after administering IVT, we do not know how this will influence the rate and management of perithrombolytic adverse events and therefore more safety and efficacy data are needed. Nevertheless, we congratulate our Bavarian colleagues for their successful implementation of a telemedical stroke network and for proving its benefit for stroke victims.2 We encourage Vatankhah and coworkers to report their early experience and to enter their BAO data also into a registry such as BASICS.
Acknowledgments
Disclosures
None.
References
- Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion: a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke. 2006; 37: 922–928.
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[Abstract/Free Full Text] - Davis SM, Donnan GA. Basilar artery thrombosis: recanalization is the key. Stroke. 2006; 37: 2440.
[Free Full Text] - Zijlstra F. Angioplasty vs thrombolysis for acute myocardial infarction: a quantitative overview of the effects of interhospital transportation. Eur Heart J. 2003; 24: 21–23.
[Free Full Text] - Keeley EC, Boura JA, Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials. Lancet. 2006; 367: 579–588.[CrossRef][Medline] [Order article via Infotrieve]
Related Article:
- Therapy of Basilar Artery Occlusion: Individual Protocols Needed
- Bijan Vatankhah, Felix Schlachetzki, and Heinrich J. Audebert
Stroke 2007 38: e29.[Full Text] [PDF]
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