Acute stroke treatment: should we be treating according to malignant profile

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HarveyCushing

HarveyCushing

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For an acute stroke should we treat the patient according to their malignant profile rather than time window? New methods like DWI and PWI support this notion. The Mlynash 2011 paper is one that has data for this. Will we start moving this way for future acute stroke therapy?
 
Access to acute MRI is a big hurdle. Having an MRI machine is one thing -- being able to immediately clear it for each and every acute stroke, with easy access from the ED even for unstable patients, is a real luxury.

Ultimately, I agree with you that patients' physiology probably means a lot more than some number on a clock, but if that clock is usually a good approximation, then it will probably remain in wider use. The MR-WITNESS study is one of the U.S. based trials looking at this. It really comes down to whether you want to personalize therapy, or sacrifice some of that granularity to make your treatment more widely applicable. Kind of a biology vs. public health debate. Maybe this sort of research will drive imaging technology toward smaller and cheaper imaging surrogates.
 
I mean we do already based on exclusion criteria, relative contraindications, and clinical judgement. It's not like everyone with an ischemic stroke coming in at 1 hour gets TPA. The question is are we going to come up with methods of evaluation which are non-burdensome enough to replace the generally accepted 3 hour window.

TN brings up a good point in available resources- at our center we have recently started doing telestroke and we are getting some good results from people that have strokes out in the boonies who 10 years ago would have had a lot more morbidity for their lack of access to treatment, and I think if we start putting in place criteria that can only be determined at a larger more advanced center we end up pulling access to people that, for some reason, continue to live in the sticks
 
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