Brain Attack!

It's likely a pretty sure bet that we've all heard of heart attacks, known in the medical parlance as myocardial infarction.  Some of us may have even had such an experience or borne witness to someone else having the experience, which is often dramatic, involving pain and a host of other unpleasant sensations, and prompting people to seek medical help quickly.  Not so for brain attack, more commonly known as stroke, or cerebrovascular accident (CVA) in medicalese. Symptoms of blood flow interruption to the brain may appear more gradually, be mistaken for something else, or seem mild or transient enough to ignore and hope it goes away. Yet a study Rick and I discuss this week on PodMed eloquently illustrates why brain attack is every bit as emergent as heart attack, as published in JAMA.

Data from almost 1400 hospitals participating in the 'Get With the Guidelines-Stroke Program,' from April 2003 to March 2012 were analyzed, comprising 58, 353 patients treated with tissue plasminogen activator or tPA within 4-5 hours of onset of stroke symptoms. Onset to treatment, abbreviated OTT time was calculated for all of the patients, with 9.3% treated in the 0-90 minute window, 77.2% in the 91 to 180 minute window and 13.6% in the 181 to 270 minutes group. The most dramatic finding of this study was that each 15 minute decrement in OTT time was inversely related to likelihood of surviving to discharge, being discharged to home rather than a long term care facility, and ability to walk, so the faster you were treated the better your chance of achieving these important outcomes.  Faster use of tPA also reduced the likelihood that an intracranial hemorrhage would occur.

Other noteworthy facts about this study included the observation that patients arriving by ambulance were more likely to receive tPA faster, and if they came during normal business hours this was also true.  Clearly, these are findings to which the medical establishment should pay heed: centers of excellence with regard to stroke should be sensitive to after hours care as well as how patients arrive.  One no-brainer is that patients with more severe symptoms of stroke got tPA sooner.  Ah, duh.  We'll call that increased index of suspicion.

This study clearly underpins observations regarding the utility of tPA and its use in ameliorating sequelae of stroke as well as death from CVA.  It is incumbent upon all health professionals to educate people around them about the signs and symptoms of stroke and the need to seek immediate medical care, even at the risk of being proven wrong.  Research being conducted here at Johns Hopkins as well as other medical centers continues to expand and refine criteria and safety parameters for using tPA and at this point, it sure looks like there is no question it can be very, very helpful, but only if the patient gets into the system and then is correctly diagnosed and treated.

Other topics this week, also in JAMA, include using MRI to assess infection after steroid injection for low back pain and autoantibodies in type 1 diabetes, and in Annals of Internal Medicine toxicity with concomitant use of statins and certain antibiotics.  Until next week, y'all live well.

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Brain Attack! | jhublogs
June 24, 2013 at 3:44 pm

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Stephen Knows Cancer July 24, 2013 at 1:32 am

Hey, I was just wondering if you happened to see that TV ad that was playing not too long ago? It was one of those attention grabbing/intense commercials which showed how the initial signs of a stroke can be very easy to miss, so it is very important that you stay vigilant. I bring it up, because I though that it was an effective ad, and this post reminded me of that. I am glad that you are conducting studies like this, because I have also read that the average age of stroke incidence has dropped over the last decade as well.


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