Modern stroke care might just be the poster child for this timeless proverb: When you know better, you do better.
Just 40 years ago, there wasn’t a lot of hope for improvement after stroke. Then better understanding of stroke rehabilitation led to a big jump forward, with specialized stroke care units becoming the norm.
As understanding of stroke progressed, it became clear that something called thrombolysis led to improved recovery. Thrombolysis refers to the process of breaking up the blood clot blocking a blood vessel in the brain. It is performed using intravenous (IV) medications.
Today, the latest improvement in stroke care is called thrombectomy. It refers to the use of mechanical methods to remove the clot. By threading an instrument into the blood vessel that is blocked, the clot can be extracted mechanically rather than broken up with medication, as in thrombolysis. This allows for more precise control of the clot and lessens the risk of bleeding complications.
Thrombolysis and thrombectomy are used to achieve the same goal—the return of blood flow to the affected area of the brain. This is called reperfusion.
Achieving reperfusion is a strong predictor of stroke recovery, and the concept “time is brain” has become the mantra of stroke care in recent years. Put simply, the more quickly you can achieve reperfusion, the better the outcome.
A new look at recent research in stroke care suggests another factor that may be as important as time and reperfusion.
Dr. Philip M. Meyers, from Columbia University Medical Center/NewYork-Presbyterian Hospital collaborated on research to help determine the key factors in predicting the success of stroke treatment. For this study, he evaluated recent research that demonstrated the excellent results of mechanical thrombectomy.
By comparing recent successful trials to older, less successful trials, a new factor—patient selection—surfaced as an important determinant of outcome after stroke treatment.
No two people are alike, and neither are any two stroke patients. For this reason, we cannot expect a single treatment to be effective for every patient.
Neurointerventionalists use advanced neuroimaging techniques to view the brain, the blood vessels that are blocked and the area that is lacking blood flow during a stroke. This imaging gives them the best information to assess which patients will benefit from thrombectomy.
At this point another key factor comes into play: The skill of the neurointerventionalist in assessing the patient and performing the thrombectomy has an impact on achieving the best outcomes.
But while time is brain, arriving in a timely manner to a hospital ill-equipped to treat stroke is not the goal. A patient having a stroke needs timely access to a facility with a skilled neurointerventionalist who can quickly perform thrombectomy for the appropriate patients. This is the formula that leads to the most success in restoring blood flow to the affected area of the brain.
Appropriate facilities and skilled operators must be accessible to everyone if we wish to diminish the impact of stroke on the individual and on society. According to Dr. Meyers and his co-authors, this may be the most important challenge in acute stroke management because we must design our healthcare delivery systems to accommodate this need.
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