There have been seven large trials of thrombolysis in acute ischaemic
stroke: ECASS, ECASS II, MAST-E, MAST-I, ASK, ATLANTIS, and NINDS. Of these
only NINDS has shown any benefit from thrombolysis. In that trial it was
given after CT and within three hours of symptom onset. There was NO 3
month mortality benefit, but treated patients were 30% more likely to have
no or minimal disability at one year. One of the specific exclusions was
"rapidly improving symptoms". I'd say the decision of the medical SHO not
to recommend thrombolysis was correct.
Mark Slade
Gen Med Consultant, Oxford
-----Original Message-----
From: Dunn Matthew Dr. (RJC) ACCIDENT & EMERGENCY - SwarkHosp-TR
[mailto:[log in to unmask]]
Sent: 11 January 2002 09:54
To: [log in to unmask]
Subject: Re: CVAs and Thrombolysis
> Within an hour of arrival complete resolution of symptoms.
> Whilst waiting for
> the bed to appear on MAU (!surely not!) Recurrence of left
> sided symptoms.
> What would you do?
> I phoned the Med SHO and said things like '?? early CT ??
> possible thrombolysis??'.
> SHO said '!!!!!!!!!! ermm speak to my reg' who said 'No No!
> No! only Newcastle
> does that in UK. No role for it etc etc'
There's a lot of good studies around showing what doesn't work in acute
stroke, including systematic reviews. Aspirin is useful (started within 48
hours) Things that don't work include anticoagulation, antifibrinolytics
(for SAH), calcium antagonists (for ischaemic stroke), gangliosides, active
control of blood pressure, mannitol and methylxanthines.
Haemodilution , steroids, hypothermia and glycerol have been used, but not
adequately studied.
Therapeutic hypothermia may work
Piractetam may improve aphasia (but does not need to be started in A and E)
tPA works with a NNT of about 25 for avoidance of death or severe
disability. I would guess the problem is persuading your radiologists to
provide scans within 6 hours of onset of symptoms. It's efficacious, but may
not be effective or cost effective.
The big thing we should be doing in A and E is improving our links with the
rehab medicine people. May not be trendy or high tech, but it works.
Having said that, a larger issue is why did you as a SpR in Emergency
Medicine seek the advice of a SHO or SpR in subacute medicine about a
medical emergency rather than asking your consultant or treating from your
own knowledge base?
Matt Dunn
British Society for Therapeutic Nihilism
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