Stroke treatment: doctors have more time to help patients, study finds

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A thrombolytic drug, which helps break blood clots, is usually given to treat ischemic stroke within four and a half hours of the onset of symptoms.

Still, the study, published Wednesday in the New England Journal of Medicine, suggests that treatment between 4½ and nine hours after the symptoms of stroke have emerged could still offer a benefit.
A thrombolytic drug called alteplase is the only drug approved by the US Food and Drug Administration to treat acute ischemic strokes. It is administered intravenously. Most strokes (about 87%) are ischemic strokes, which occur when the artery that supplies the brain with oxygen-rich blood is clogged, often by a blood collection called a clot.
Dr. Carmelo Graffagninob, a vascular neurologist at Duke Health and Medical Director of the Duke Comprehensive Stroke Center in Durham, North Carolina, pointed out that while the results of this new study are "interesting". weighed up to make formal changes to the treatment guidelines for cerebrovascular accidents.

With additional research, however, this could happen.

"What was really exciting, is that in vascular neurology, or stroke, we were still forced to treat patients in a hurry, rather than by what was actually going on in their brains," said Graffagnino, who did not participate in the study of research presented at the International Stroke Conference in February.

"We think it's only the beginning of the use of biology and not the stopwatch to treat the right patients," he said.

In the United States, a person suffers a stroke every 40 seconds, according to US Centers for Disease Control and Prevention.

An advantage for rural or low-income health centers

The new study looked at 225 adult stroke victims between 2010 and 2018 in Australia, New Zealand, Taiwan and Finland.

According to new study, 1 in 4 in the world will have a stroke at age 25 or older

Patients were randomly assigned to thrombolytic therapy or placebo between 4 ½ and 9 hours after the start of their stroke.

The researchers found that recanalization, or restoration of blood flow, was performed 24 hours after stroke in 67.3% of patients in the treated group, compared to 39.4% of the placebo group.

The study also found that the degree of disability after stroke, measured on what is called a modified Rankin scale, was nil or minimal in a larger number of patients in the treatment group at 35.4% compared with placebo patients at 29.5%. .

According to the study, the percentage of patients who died within 90 days of treatment or placebo did not differ significantly from one group to the next.

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"About 80% of patients in this study had large vessel clots, which means that they would actually be candidates for mechanical thrombectomy – to remove the clot with the help of a catheter – and the success rate of the extraction of a clot by catheter is much higher than the success rate of the dissolution of a clot with a drug, "said Graffagnino.

If a patient may not have access to thrombectomy, however, the study suggests that thrombolysis may be a beneficial option.

"This has very serious consequences for the most distal regions, rural hospitals further away from advanced treatment centers, for low- and middle-income countries where interventions, such as thrombectomy, are limited because of their resources" , did he declare.

According to the World Health Organization, about 70% of strokes and 87% of stroke-related deaths and disabilities occur in low- and middle-income countries.

The new study had some limitations, including a smaller sample than expected, as the research was stopped early after the release of positive results from a previous trial.

"The era of time-based treatment … maybe finally coming to an end"

The new study "underscores the importance of individualizing acute stroke treatment and not just excluding patients because of the time they were found normal," said Dr. Fadi Nahab , medical director of the stroke treatment program at Emory Hospital, who did not study, wrote in an email.

Many hospitals only offer IV alteplase if a patient has experienced stroke symptoms within 4 and a half hours and excludes those who might have woken up. 39, a sleep with stroke symptoms, because the start time would not be known, explained Nahab.

The extension of this period therefore provides "to hospitals stroke treatment centers that have additional opportunities to treat patients who arrive within 4.5 to nine hours or who develop new stroke symptoms. when you wake up, "he said.

Although more research is needed to validate the results of the study, "the era of time-based treatment with intravenous alteplase in patients with acute stroke is coming to an end" said Dr. Randolph Marshall, a neurologist at Columbia University in New York. , writes in an editorial published next to the new study.

"In 2013, only 6.5% of patients hospitalized for ischemic stroke had intravenous thrombolysis treatment," he wrote. "Extending the window of time for treatment could result in more patients eligible to receive treatment for acute stroke."

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