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CMAJ
CMAJ - May 2, 2000JAMC - le 2 mai 2000

Treating stroke

CMAJ 2000;162:1273

In response to: R. Verbeek
Richard Verbeek expresses the all-too-common concern that triaging acute stroke patients to stroke centres will overwhelm hospital and emergency department resources. We agree that it would be ideal if every hospital with a CT scanner could offer thrombolytic therapy for stroke. While this is not the case now, with improved telemedicine this might become feasible in the very near future. In our opinion thrombolytic therapy for stroke has many parallels with thrombolysis for acute myocardial infarction, although the therapeutic window is tighter (under 3 hours) and the neurology is more complex. The Cochrane analysis suggests that when tissue plasminogen activator is used for acute stroke 140 disabilities are prevented per 1000 treated patients. For acute myocardial infarction, 35 deaths are prevented per 1000 patients treated with tissue plasminogen activator.

We believe that stroke expertise in highly organized centres is now required and this expertise should extend beyond urban centres through use of modern communications. The triage of patients with acute ischemic stroke is a new but rapidly developing art. It is not surprising that early attempts failed to show high sensitivity and specificity. A new scale, the Los Angeles prehospital stroke screen, has been prospectively validated and shows a positive predictive value of 97% and a negative predictive value of 98%.1 As this scale becomes more widely used it should alleviate the concern that Verbeek articulates.

It is wrong to think that triage should occur in the emergency department of community hospitals so that specific patients can then be sent on to tertiary stroke centres. Simply stated, there is not enough time when time is brain. Analysis of the National Institute of Neurological Disorders and Stroke (NINDS) stroke trial shows a reduction in benefit for every minute of increased time from onset to treatment.2 Every month in Calgary we are disappointed when a patient arrives late because transport was delayed to allow assessment at an outlying centre.

Acute stroke care is now evolving as acute cardiac care evolved over the last 25 years. Verbeek has indeed observed this and radically proposes to put defibrillators into lay hands [Review].3 We suggested that thrombolysis is like a defibrillator of the brain [Commentary]4 and we predict that our colleagues in the emergency department, with increased knowledge of stroke and assistance by telemedicine to evaluate CT scans, will allow local community hospitals to directly implement effective stroke care to those presenting within the therapeutic window.5

Alastair M. Buchan
Thomas E. Feasby
Department of Clinical Neurosciences
University of Calgary
Calgary, Alta.

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References

  1. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field: prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke 2000;31:71-6. [MEDLINE]
  2. Marler J, Tilley BC, Lu M, Brott T, Lyden P, Broderick JP, et al. Earlier treatment associated with better outcome in the NINDS t-PA Stroke Study [abstract]. Stroke 1999;30:244.
  3. Schwartz B, Verbeek PR. Automated external defibrillation: Is survival only a shock away? CMAJ 2000;162(4):533-4. [MEDLINE]
  4. Buchan AM, Feasby TE. Stroke thrombolysis: Is tissue plasminogen activator a defibrillator for the brain? CMAJ 2000;162 (1): 47-8.
  5. Buchan AM, Barber PA, Newcommon N, Karbalai HG, Demchuk AM, Hoyte KM, et al. Effectiveness of t-PA in acute ischemic stroke: Outcome relates to appropriateness. Neurology 2000;54:679-84. [MEDLINE]

© 2000 Canadian Medical Association or its licensors