STROKE RESEARCH Study: Some victims not getting key drug

Records of more than 400 patients with clot-related strokes were reviewed.
SCRIPPS HOWARD NEWS SERVICE
Nearly a third of patients who arrive at hospitals with stroke symptoms so mild they're judged "too good to treat" with clot-dissolving drugs die or go to a rehabilitation facility, according to a new study released online last week.
When a stroke is caused by a clot blocking a blood vessel, doctors try to limit the damage by giving the patient tissue plasminogen activator (tPA). It can usually safely dissolve a blockage if it's given within three hours of the onset of symptoms.
Nearly 700,000 Americans suffer this type of stroke each year, with 28 percent of victims younger than 65 years of age. Clot-induced "brain attacks" account for about 80 percent of all strokes. About 25 percent of all strokes are fatal and the attacks are the third-leading cause of death in the nation.
Many stroke patients don't get to the hospital early enough to get the drug. But even when they do, doctors have to weigh the small but real risk that the drug could cause a brain hemorrhage. Because of this, many patients with less severe symptoms, or who seem to be improving, may not get the drug.
Researchers at Massachusetts General Hospital in Boston reviewed the records of more than 400 patients with clot-related strokes who came to the hospital's emergency department between 2002 and 2004.
Of the 128 patients who arrived within the three-hour treatment window, 71 did not receive tPA. More than half of those patients were considered "too good to treat," mainly because their symptoms were stable and mild, or had improved rapidly.
But of those 41, two died in the hospital and nine others wound up in a rehabilitation center because of continuing neurological problems. "So about 30 percent of those patients judged 'too good to treat' either died or were discharged to a rehabilitation facility," said Dr. Eric Smith, a neurologist at the hospital and lead author of the study, which will appear in print in the November issue of the journal Stroke, a publication of the American Heart Association.
"Unfortunately, we were not able to find any features that could predict which of the untreated patients would have problems," said Dr. Smith, who is also an instructor in neurology at Harvard Medical School.
Borrowing blood
He explained that, in some patients, symptoms that improve early in the course of a stroke might be the result of the affected area of the brain "borrowing" blood from nearby areas. But if the initial blockage continues to affect the primary blood supply and is not removed, symptoms may eventually worsen.
"Right now, we can only recommend that physicians be a little more cautious in deciding against tPA treatment," Dr. Smith said. "We can suggest more attention be paid to patients' ability to walk -- something that often is not evaluated -- since gait disturbance was a reason why several of the patients could not go home.
"But we really need to find ways to predict who will do poorly without tPA, and for that, we'll need larger trials involving several institutions."