Annals of the New York Academy of Sciences
-
Ann. N. Y. Acad. Sci. · Sep 2012
ReviewImpact of regional pre-hospital emergency medical services in treatment of patients with acute ischemic stroke.
Stroke is a major public health concern afflicting an estimated 795,000 Americans annually. The associated morbidity and mortality is staggering. Early treatment with thrombolytics is beneficial. ⋯ Ambulance transport of stroke patients to the hospital has demonstrated improvements in key benchmarks such as door to physician evaluation, door to CT initiation, and increased thrombolytic treatment. Pre-hospital notification of the impending arrival of a stroke patient allows for vital preparation in the treating emergency department, and improving timely evaluation and treatment upon arrival of the stroke patient. EMS systems are a vital component of the management of stroke patients, and resources used to improve these systems are beneficial.
-
Acute ischemic stroke is a time-critical emergency for which thrombolytic therapy is the only medical treatment. Many patients who would benefit from this treatment are deprived of it due to delays. Failure to call for help rapidly is the main obstacle, but even when the call is made in time, the prehospital evaluation, transportation, and emergency department (ED) diagnostics often take too long to treat the patient with thrombolysis. ⋯ The intersection of the pre- and in-hospital care is of special importance. With successful protocols and good communication between the emergency medical service and ED, delays can be significantly reduced. On the basis of our experience, 94% of patients can be treated within 60 min of arrival, based largely on using the prehospital time effectively.
-
Ann. N. Y. Acad. Sci. · Sep 2012
Comparative StudyIntra-arterial vasodilator use during endovascular therapy for acute ischemic stroke might improve reperfusion rate.
Treatment of acute ischemic stroke (AIS) is an evolving field. New treatment options are still needed in order to achieve greater success rates for arterial recanalization. Intra-arterial therapy (lAT) is an option for AIS patients who are not good candidates for intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) or where it has failed. ⋯ Although lAT recanalization and reperfusion rates of large vessel occlusion are much higher than they are for i.v. rt-PA, IAT's radiological efficacy is still far from perfect. Vasodilator use during IAT for AIS may increase the recanalization and reperfusion rates of such therapy. In this report, we describe the radiographic and clinical outcomes in a cohort of AIS patients who received intra-arterial (i.a.) vasodilators during IAT and summarize the role of i.a. vasodilators in the process of recanalization and reperfusion.
-
Ann. N. Y. Acad. Sci. · Sep 2012
ReviewImaging-based selection in acute ischemic stroke trials - a quest for imaging sweet spots.
Ischemic stroke is a very heterogeneous disease that limits the efficacy of acute stroke treatments. Future trials will require advanced imaging to select patients for specific treatments. ⋯ As an alternative to mismatch when addressing stroke, one needs to know the size of the initial irreversible lesion (core), the presence and site/extent of occlusion (clot), and presence of leptomeningeal back filling and Willisian filling (collaterals). These can be summarized as the "3C" approach of core, clot, and collateral interpretation, which together can represent an imaging sweet spot, particularly for time-efficient endovascular treatment trial design.
-
Hemorrhagic transformation (HT) associated with recombinant tissue plasminogen activator (rt-PA) complicates and limits its use in stroke. Here, we provide a focused review on the involvement of matrix metalloproteinase 9 (MMP-9) in rt-PA-associated HT in cerebral ischemia, and we review emerging evidence that the selective inhibitor of the sulfonylurea receptor 1 (Sur1), glibenclamide (U. ⋯ A retrospective clinical study comparing outcomes in diabetic patients with stroke treated with rt-PA showed that those who were previously on and were maintained on a sulfonylurea fared significantly better than those whose diabetes was managed without sulfonylureas. Inhibition of Sur1 with injectable glyburide holds promise for ameliorating rt-PA-associated HT in stroke.