Where do we go from here?
More than 20 years after IV tissue plasminogen activator was officially approved for use in acute ischemic stroke, now data suggest mechanical thrombectomy is superior, regardless of whether tPA is given.
Granted, these are preliminary trials, and a lot more research needs to be done: randomized studies, determinations of which patients are the best candidates, which devices are most useful, etc.
This led to an email exchange between another neurologist and me recently, wondering if we should be notifying the interventionalists, too, as soon as a nonhemorrhagic stroke is rolled in. Why should we have all the fun? Heck, why bother me at all? If they’re better at it, call the interventionalists and let me sleep.
Of course, it’s not that simple. The data thus far suggest thrombectomy is best when used in anterior circulation strokes, with a National Institutes of Health Stroke Scale score of greater than 6, so obviously we shouldn’t be calling them in on every case.
You have to balance that against legal issues. It certainly isn’t too far-fetched to imagine being sued because you didn’t call an interventionalist, or another neurologist testifying that you fell below the standard of care by not doing so. The right person will say that about anything, regardless of clinical data.
This is still up in the air right now, as I doubt the interventionalists want to take acute ischemic stroke off our hands, nor do we want to give it up, either. It’s a disorder of the brain, and that is what we deal with, isn’t it?
The bottom line is that rumors about the death of tPA in acute ischemic stroke are greatly exaggerated. Only time will tell.
Medicine, for better or worse, is an inexact science. No one can predict outcomes, adverse reactions, or complications with 100% certainty. Which treatment will work best for which patient is never known. That’s why we need controlled trials to know which odds are best overall, and take it from there. Preliminary trials can be very helpful at pointing us in the right directions, but are for from definitive. As with so many other things, your mileage may vary.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
