Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Preventive Treatment for Patients with Cerebral Ischemia--and Macular Degeneration: What to Do?
- Nancy Yanes-Hoffman (1 February 2003)
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Problems with thrombolysis in ischemic stroke
- ashish aneja (5 February 2003)
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Thrombolysis for acute ischaemic stroke in the accident and emergency department
- Omar Quaba, Colin E. Robertson (6 February 2003)
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First do no harm
- Richard G Fiddian-Green (6 February 2003)
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Waiting for Confirmation
- Michael J. Beyak (13 February 2003)
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thrombolysis in ischaemic stroke.
- dr.manan vasenwala (23 July 2003)
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Zero tolerance for complications and deaths from medical therapy.
- Richard G Fiddian-Green (25 July 2003)
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Nancy Yanes-Hoffman, WRITING DOCTOR NYHealthCare Communications Group, 16 San Rafael Dr, Rochester, NY 14618, USA
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The dilemma is obvious. Yet virtually no one seems to be addressing it. With cerebral ischemia rampant among older persons and with 15 million individuals in the United States who suffer from choroidal neovascularization (the "wet," therefore blinding, form of macular degeneration), what preventive medication--and what research--is available on treating these people with TWO swords of Damocles hanging over their heads? Medline contains ONE article, which tells us what we already know: prophylactic aspirin produces retinal hemorrhage. Is anyone studying this problem? Does anyone have any possible answers? All suggestions gratefully received. Competing interests: None declared |
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ashish aneja, Clinical Assistant Instructor SUNY Downstate Medical Center, NY, 11203
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Dear Sir, There is one very compelling reason why thrombolysis in stroke is not a very attractive option as opposed to myocardial infarction. The 3 hour "window" for thrombolytic therapy in ischemic stroke is usually more poorly defined than the onset of chest pain and physicians are reluctant to initiate thrombolysis in the ER setting for this reason as well. MRI Angiogram/SPECT guided thrombolysis may be considered an option in the future since it has the potential to detect small intracerebral bleeds while t-PA is being administered. This is a an attractive option to prevent full-blown hemorrhagic stroke as a complication. Thanks
Competing interests: None declared |
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Omar Quaba, sho plastic surgery ninewell's hospital, dundee, Colin E. Robertson
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Dear Sir, Warlow and Wardlaw state that, 'what is good for heart attacks is still not good enough for brain attacks'(ref1). We would like to point out that we looked at the feasibilty of thrombolysis for acute ischaemic stroke in Edinburgh's only accident and emergency department. We concluded that the term 'brain attack' was emotive and that by no means could this be compared to a 'heart attack' when it came to treatment with thrombolysis. Lack of significant randomised clinical trials, difficulty in diagnosis, doubts about risk-benefit ratio and delays in CT scanning were all cited as problems(ref2). More importantly, in the best case scenario only 6 (6.4%) of 94 patients in our study would have been eligible for thrombolysis. This is assuming that the diagnosis had been confirmed by CT within 3 hours of onset of symptoms. The reality of current constraints in National Health Service practice mean that even fewer patients than this are likely to benefit from thrombolysis. References: (1) Warlow C. and Wardlaw J. Therapeutic thrombolysis for acute ischaemic stroke. BMJ 2003; 326: 233-234 (2) Quaba O. Robertson CE. Thrombolysis and its implications in the management of stroke in the accident and emergency department. Scottish Medical Journal 2002; 3: 57-9 Competing interests: None declared |
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Richard G Fiddian-Green, None None
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The need for better support for the management of strokes is acknowledged. The very real danger of thrombolysis making patients worse by converting an ischaemic stroke into an haemorrhagic stroke, a four fold increase in risk, is, however, of great concern especially as the risk appears to be unpredictable in individual cases. Perhaps we should be thinking of a completely different approach such as isolating arterial perfusion with angioplastic balloons placed in both carotid and vertebral arteries and replacing the infusion of blood with an infusion of cold UW solution or oxygenated Perflubron. This would have the potential of everting the risk of haemorrhage being induced by thrombolysis and might even improve greatly the opportunity for limiting the degree of irreversible brain damage induced by the stroke. A similar approach might even be fruitfully applied to the management of head injuries (1). We really do need to think out of the box if we are to make dramatic improvements in the management of these distressing conditions. 1. Forty years later Richard G Fiddian-Green bmj.com/cgi/eletters/325/7364/598/a#27780, 12 Dec 2002 Competing interests: None declared |
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Michael J. Beyak, Research Fellow Hotel Dieu Hospital, Kingston, Ontario, Canada, K7M 5G2
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As has been illustrated by the editorial by Drs Warlow and Wardlaw, the evidence in favour of thombolysis in acute stroke arises from one randomised trial. All other trials performed were either equivocal or negative. Notwithstanding differences among these trials in terms of drug, dose, and timing, this should prompt us to seek reproduction of the favourable results seen in the NINDS trial. Despite this, in the more than three years since the publication of the 1 year NINDS data, there have been no such comfirmatory data published. Given the potential for serious harm with the use of these agents, we must not be too hasty to incorporate them into "standards of care" as many associations already have. We must be careful when evaluating new treatments to consider all of the available evidence, and not just those results that we would most hope are true. Competing interests: None declared |
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dr.manan vasenwala, consultant-cardiologist k.india.k.heartcenter, aligarh-202002
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i wonder if similar problems are encountered in thrombolysis in stroke as in myocardial infarction. during thrombolysis in myocardial infarction, there are reperfusion arrythmias. are similar undesirable "neuronal activity" also seen in stroke? also is there a "no re flow" phenomena? a delay in thrombolysis can convert a bland myocardial infarct into a hemorrhagic one especially after the permissable 8 hours or so. one should anticipate a similar condition in brain, thus the window will probably need to be short. Competing interests: None declared |
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Richard G Fiddian-Green, None None
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This was an excellent review(1). I agree with the conclusion "basic plumbing should come first". One problem I have with medical treatment in general and with thrombolysis for strokes in particular is that there is always a risk- benefit trade off. The implication is that these treatments inevitably violate the first principle of patient care, first do no harm. In the case of thrombolysis for a stroke that harm can be especially devastating for patients and costly for relatives, hospitals and healthcare authorities potentially in rendering a patient an insitutionalised vegetable or dead. I have chastised surgeons, most recently the cardiac surgeons(2,3,4), for accepting complications and deaths as an inevitable part of doing surgery even in "high-risk" patients with co-morbidities and have called for zero tolerance for them. Once one accepts that complications and deaths are an inevitable part of doing elective surgery, which they are not for many avoid them today, one violates the principle of first doing no harm. I believe that zero tolerance for complications and deaths should apply to all interventional procedures and even medical therapy even for emergencies. The standard of care in many centers has advanced to the degree where this is no longer an unrealistic expectation in elective cases. Whilst is is more difficult to avoid complications and deaths in emergencies it is in these circumstances that the most is to be gained from implementing a policy of zero tolerance. To do otherwise is to risk fostering a climate of therapeutic nihilism which can have unintended consequences (5,6). 1. Therapeutic thrombolysis for acute ischaemic stroke Charles Warlow and Joanna Wardlaw BMJ 2003; 326: 233-234 2. Zero tolerance for deaths and complications in cardiac surgery Richard G Fiddian-Green bmj.com/cgi/eletters/327/7405/13#34530, 17 Jul 2003 3. Playing Russian Roulette Richard G Fiddian-Green bmj.com/cgi/eletters/326/7393/804#31130, 11 Apr 2003 4. Failures of surgical care and outcome from cancer surgery Richard G Fiddian-Green bmj.com/cgi/eletters/320/7239/895#7229, 31 Mar 2000 5. Therapeutic nihilism Richard G Fiddian-Green bmj.com/cgi/eletters/325/7368/836#26190, 11 Oct 2002 6. Fostering therapeutic nihilism in the recipient? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7368/836#26289, 15 Oct 2002 Competing interests: None declared |
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