Imaging Resets the Stroke Clock

from the International Stroke Conference in San Antonio

Until recently, acute stoke treatment ran strictly by the clock. Now that’s changing.

image courtesy Flickr user teh kankaik

First line treatment, intravenous infusion of a clot-disolving drug like tissue plasminogen activator (tPA), initially had a 3 hour time window, recently pushed back to 4.5 hours. More aggressive, endovascular treatments aimed at removing blood-blocking clots–intra-arterial tPA, the Merci clot retriever, and the Penumbra clot suction device–have received time limits of 6 hours (for intra-arterial tPA) or 8 hours (for the mechanical devices).

But interventional neurologists at several U.S. stroke centers now use these treatments beyond the 8 hour limit on selected patients, those with enough salvageable brain when assessed by perfusion CT or by diffusion-weighted MRI.

This approach received a boost at the Stroke meeting last week, when a review of 237 patients selected this way showed that encovascular reperfusion treatments were safe and effective for many patients who started on treatment anywhere from 8-111 hours after their stroke began.

“A lot of patients are deprived treatment based on time,” said Harvard neurologist Raul G. Nogueira, who reported the results. “It’s time to get away from the time window. No question that sooner is better, but some patients benefit later.”

Dr. Nogueria acknowledged the next step is to prove this in the prospective study now being assembled. In the meantime, his findings give some validation to a practice that’s become routine at many U.S. stroke centers.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Cardiovascular Medicine, Emergency Medicine, IMNG, Internal Medicine, Neurology and Neurological Surgery, Surgery

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