New data urges faster treatment of stroke victims

By Daniel Q. Haney

Associated Press

SAN ANTONIO — Speeding up delivery of clot-busting drugs to stroke victims could greatly improve their chances of recovery, even if doctors manage to shave off just a few minutes, a new analysis shows.

Medicines that break up clots are the only effective treatment in the hours after a stroke. To do any good, however, they must be administered before brain cells die.

The current standard requires that treatment begin within three hours of the onset of the stroke, and most patients who make it to the hospital in time get the drugs within the last half-hour before that deadline.

Now, a new report finds that earlier treatment — in the first 90 minutes after symptoms begin — nearly triples the chances of full recovery compared with treatment that starts later.

"If we can convince people that every minute counts, it could be a big boost," said Dr. Thomas Brott of the Mayo Clinic in Jacksonville, Fla. "We can’t relax for one minute. With every minute, brain cells are dying by the tens of thousands."

Brott presented his findings Saturday at the annual meeting of the American Stroke Association in San Antonio.

TPA — tissue plasminogen activator — can dissolve clots that block arteries and has long been the mainstay of heart attack treatment. In 1995, a federally funded study showed it could reverse strokes the same way if given within three hours of symptom onset.

As a result of that study, the three-hour time window became the standard.

But some specialists say that isn’t good enough. Faster treatment will better the odds that patients will escape with their thinking power and other functions intact, they say, and the latest analysis supports that belief.

Brott and colleagues combined data from six studies of clot-dissolving drugs involving 2,776 patients in 18 countries.

They found that those treated within the first 90 minutes after the start of symptoms have almost three times the chance of a full recovery compared to people who are not treated. However, those treated in the second 90 minutes have only a 1.5 times greater chance of recovery.

"We conclude that time, in fact, is brain," he said. "The earlier the treatment, the more the benefit."

Brott said hospitals should strive to start treatment — the so-called door-to-needle time — within an hour of the patient’s arrival.

Dr. Joseph Broderick of the University of Cincinnati said hospitals need to work out systems to coordinate treatment to shave off delays.

"Hospitals that won’t do it right should not be taking stroke patients, but most community hospitals can do this," he said. "It’s not rocket science, but it has to be organized properly."

Currently only about 2 percent stroke patients end up getting TPA. The biggest barrier is that they arrive at the hospital too late. Many ignore their symptoms or don’t realize anything is wrong.

Once at a hospital, doctors must make sure the stroke is actually caused by a clot in the brain. Broken blood vessels can also cause strokes, and giving TPA to those people makes the situation worse.

Hospitals must give patients CT scans, have them read by a neurologist to make sure there is no bleeding, and then begin administering TPA through a catheter.

Small delays quickly add up, especially if hospitals work step by step rather than getting everyone involved in the treatment moving simultaneously.

"You have to take a drop everything approach," said Brott. "That is difficult for a neurologist who has an office full of patients or is home 15 miles away from the hospital."