What is good for heart attacks is still not good enough for brain attacks

Therapeutic thrombolysis for acute myocardial infarction is standard practice, but not so for ischaemic stroke, the “brain attack” equivalent of heart attack. This is partly because stroke is more complicated: intracerebral haemorrhage must be excluded by imaging, and more vascular pathologies than atheroma underly ischaemic stroke (for example, intracranial small vessel disease and embolism from the heart). Furthermore, coronary care units make research on heart attacks relatively easy, whereas research on acute stroke still often takes place in general medical wards. With stroke units, this will be less of a problem. Research on strokes is woefully underfunded in comparison to research on heart attacks.1 But, if thrombolytic “unblocking the pipes” works for acutely occluded coronary arteries, it should work for acutely occluded brain arteries, provided reperfusion does not make matters worse by increasing cerebral oedema and haemorrhagic transformation. As usual, the balance of benefit and risk is best determined by randomised trials—facts, not opinions and theories.

Here again there is a difference between heart attack and brain attack. For the former, about 60 000 patients …