Magazine article Clinical Psychiatry News

Stroke Guidelines Called 'Hopelessly Outdated'

Magazine article Clinical Psychiatry News

Stroke Guidelines Called 'Hopelessly Outdated'

Article excerpt

Current guidelines on the use of thrombolytic therapy for acute ischemic stroke are "hopelessly outdated," Louis R. Caplan, M.D., said in an editorial that accompanied several reports of patient outcomes studies published in the Journal of the American Medical Association.

The guidelines, which are nearly a decade old, exclude from thrombolytic therapy patients who may indeed benefit from it and do not consider the major advances in diagnostic technology that have occurred over the past 2 decades, said Dr. Caplan, chief of the division of cerebrovascular diseases at Beth Israel Deaconess Medical Center in Boston.

The results of two recent studies on outcomes after thrombolysis are "an important reminder" that few patients with ischemic stroke receive thrombolytic therapy, according to Dr. Caplan (JAMA 2004;292:1883-5).

On the other hand, this treatment "is not a panacea and may actually cause intracerebral hemorrhage or death" in some patients, said Dr. Caplan, who is also professor of neurology at Harvard Medical School, Boston.

In a study by the German Stroke Registers Study Group on predictors of in-hospital mortality after thrombolysis, only 3% of almost 60,000 patients presenting with acute stroke received intravenous tissue plasminogen activator (tPA). Of treated patients, 10% died during hospitalization.

In the second study, more than half (51%) of 216 patients treated with alteplase in London, Ont., failed to improve significantly after treatment when the published guidelines were followed.

Neither study reported causative vascular lesions, or the extent of infarction before or after treatment--information that can be identified with modern imaging techniques, Dr. Caplan noted.

"If the present guidelines continue to be followed, as in the [two studies], physicians will never know which patients with what degree of infarction and with what vascular lesions and at-risk tissue will benefit from thrombolysis," he said.

Nor will physicians know "whether intravenous, intraarterial, or combined intravenous and intraarterial [therapies] are best and in what circumstances," Dr. Caplan said. "Clinicians also will not know how alteplase compares with other promising newer thrombolytic agents and, possibly, with other therapies. …

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