Monday, December 17, 2012

Pouring Money Into Prehospital Stroke Thrombolysis


Staying consistent with the "brain attack!" slogan folks developed for stroke, the innovations in treatment continue to progress in their attempts to mimic myocardial infarction.  In myocardial infarction, a great deal of focus has been placed on rapid diagnosis and either thrombolysis or interventional catheterization.  This extends to the prehospital arena, with experimentation with ECG transmission, pre-hospital lytics, and pre-hospital cath lab activations.

For stroke, they're still trying to replicate this pre-hospital diagnosis and treatment – made slightly more complex because the diagnostics involved requires CT scanning.  However, with enough funding from telehealth and imaging industry, "mobile stroke units" have been created for feasibility evaluations. 

And, these authors have certainly demonstrated that it is feasible, diagnosing 48 acute strokes in the prehospital setting and giving half of them thrombolysis.  One patient given rt-PA had sepsis rather than an acute stroke, which is of uncertain significance in an underpowered feasibility case series such as this.

However, there's a difference between can and should.  I'm uncertain whether we should even be exploring the can portion in this pilot, considering should means a grossly excessive allocation of resources for a therapy of uncertain benefit.  Given the small absolute benefits seen in the handful of trials that even showed a benefit, I can't possibly see how trials of pre-hospital lytics could favor anything but surrogate endpoints, rather than patient-oriented endpoints.  30 minutes faster to TPA?  At what cost, and did outcomes change?

I won't fault the authors for their interesting experiment – as long as they don't seriously propose it as The Future based on our current evidence.

"Prehospital thrombolysis in acute stroke : Results of the PHANTOM-S pilot study" 
www.ncbi.nlm.nih.gov/pubmed/23223534

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