Monday, June 15, 2009


The cream of neurology met in San Diego in Feb 2009, to review and update the management of acute strokes. This was published in Medscape, and now availbale on-line for review. Interesting. Looks like there have been much advance since my medical officer days. A stroke occurs when a brain artery gets blocked, causing sudden lack of blow flow to the brain and that results in sudden lost of function of that part of the brain that is supplied by that blood vessel. This usually results in paralysis on one half of the body. This sudden paralysis, can be catastrophic and devastating, causing an active individual to suddenly become dependant, not being able to take care of his/her own needs. Besides the obvious functional disability, there is the emotional and mental disability, resulting in a severe transformation of that persons whole life outlook. Yes, a stroke is devastating.
The neurologist have been working very hard to improve stroke outcomes. As a cardiologist, I can see that many of their advances is modelled on the advances in cardiology in the treatment of acute heart attacks. They now also have what they term, acute brain attack ( for strokes ) and the call to set up stroke units in major hospital, in an attempt to improve on the acute management of strokes. Yes, they are also on to the use of IV and also intra-cerebral arterial r-TPA as a acute thrombolytic agent to revascularise the infarcted brain. Of course, hemorrhage in the brain is much less well tolerated the myocardial hemorrhage following thrombolysis in AMI. Their time window for the benefit of rTPA is 3-4.5 hrs, not unlike the time window for AMI thrombolysis. Just as the acute ECG is all important for us, the acute CT scan of the brain is very important for them. Some stroke units also do acute CT angiograms to better demarcate the territory of supply. The neurologist have also tried acute angioplasty and the use of stents, but the conference concluded that there was not yet enough evidence to show benefit, and so is not yet ready for widespread use. Acute brain surgery also has a role, but a very limited role. Hemicrainectomy, prolongs life but does not improving quality of life ( if you know what I mean ).
I suppose, in many sense, the neurologist is not wrong in following many of the approaches of the cardiologist. Afterall, we are dealing with blood vessels and vascular supplies, and when occluded, a sudden loss of blood supply and their consequences. In this sense, stroke units ( like CCUs ) and thrombolysis and door-to-needle time becomes important similar concepts. We await large scale clinical trials ( I do not think that they can be blinded or randomised ) to show us if primary angioplasty for strokes will improve outcomes when compared to IV thrombolysis.
What I did not see enough in their San Diego conference was an emphasis on stroke prevention. Control of blood pressure, prevention of diabetes and obesity, stop smoking, lower serum cholesterol, and LDL-cholesterol, adequate exercise, adequate rest and sleep, are all as important, if not more important, in my opinion, than IV r-TPA and acute stroke units. Maybe there is nothing new there. I felt that strokes, like CAD and heart attacks are better prevented. An acute stroke is in many ways a failure of prevention, and doctors must do their most to avoid that. It is something that many doctors personally too, would like to avoid, myself included.

1 comment:

pilocarpine said...

thx for d update!!