Good news for stroke sufferers

January 28, 2018 9:23 PM

An existing treatment for stroke is much more useful than previously thought. How much more useful? "“These striking results will have an immediate impact and save people from lifelong disability or death,' Dr. Walter J. Koroshetz, director of the National Institute of Neurological Disorders and Stroke, said in a statement. 'I really cannot overstate the size of this effect.' A thrombectomy is an operation to remove large blood clots from the brain. Traditionally, the operation's effective time window was thought to be six hours. A recent clinical trial has determined that the window is actually up to sixteen hours for certain types of strokes. The study was terminated early due to its unambiguously good results.
posted by storybored (16 comments total)

Cool.
posted by Tell Me No Lies at 9:53 PM on January 28, 2018

Thanks for this. I hope it doesn't lead to anyone feeling less urgency in getting stroke treatment, as delay makes recovery so much less possible.
posted by anadem at 9:59 PM on January 28, 2018 [1 favorite]

Caveat: only a subset of stroke patients would qualify for this treatment depending on the size and location of the stroke.
posted by Pantalaimon at 10:09 PM on January 28, 2018

The lack of intellectual rigor in medicine makes me crazy. How many people could have been helped if a real study had been done sooner? Why is the most well funded and well subscribed STEM discipline allowed to be run like it's a medieval guild? I hesitate to even include it in the term "STEM", that's how far medicine is from it's own standard of "evidence based". Imagine if engineering was run like medicine- we'd all have died in a bridge collapse by now.
posted by fshgrl at 11:11 PM on January 28, 2018 [12 favorites]

I have waaay too many people in my life at risk for a stroke. Every new advance in treatment makes me feel a bit better.
posted by The Underpants Monster at 11:53 PM on January 28, 2018 [4 favorites]

The best part is that this appears to be a well-known and well-practiced procedure to boot!
posted by Samizdata at 12:46 AM on January 29, 2018

Thrombectomy is a relatively new procedure - if you follow the links in the article the seminal technologies involved were only developed/published in 2014. Prior to this there was no mainstream interventional radiological treatment for stroke.

You can experiment on bridge technologies in a field without it being a human rights issue.
posted by chiquitita at 2:18 AM on January 29, 2018 [17 favorites]

> I hope it doesn't lead to anyone feeling less urgency in getting stroke treatment

The difference between six and sixteen hours is generous when the patient is already in the hospital, but I don't think it's going to be enough to make people feel like they can safely stop for dinner en route to the emergency room.
posted by ardgedee at 4:16 AM on January 29, 2018 [2 favorites]

That's amazing news. It's been five years next month since my dad had a stroke. It's actually quite tricky being a first time stroke patient. Out of the five classic symptoms, dad was only dizzy. He managed to drive himself to a doctor, who told him he was just dizzy. When he finally went to the ER, he spent three hours there :S Once they did a CAT scan, everyone sprang into action. I only share this because of dad's experience. All the medical treatment in the world won't mean a thing if no one realizes you are having a stroke.
posted by Calzephyr at 6:13 AM on January 29, 2018 [14 favorites]

I've spent a lot of time in the recent past thinking about different forms of clinical trials (and nonclinical experiments), and it's actually really nice to see a case where the trial was ended not for adverse outcomes, but because the experimental method was so useful that it would be unethical to not offer it to everyone who can benefit.
posted by Making You Bored For Science at 7:18 AM on January 29, 2018 [7 favorites]

how far medicine is from it's own standard of "evidence based"

from my limited perspective, training for medical practitioners is very evidence-based (my partner was taught to be cautious about the racial bias in perceived pain tolerance when she was a medical student). where you find most abuse is from practitioners who are years out of school, relying on their own experiences, especially those who only went into the field for its high earning potential and/or prestige
(ex surgeons, dermatologists, Dr. Oz, etc). there's also something to be said about the NIH's funding being slashed since GW ruined the economy through non-regulation of shadow banks and Obama was then forced to implement austerity measures

You can experiment on bridge technologies in a field without it being a human rights issue.

yes, but you can and do still have numerous instances of human rights abuses in the field of medical research, particularly when it concerns those who are perceived by a white supremacist society as subhumans, an issue that, as noted above, that still plagues us today
posted by runt at 7:19 AM on January 29, 2018 [7 favorites]

Okay, but the attempt to avoid those human rights abuses is precisely why medicine can be slow to experiment with new treatments, or to push at the limits of old ones.
posted by Acheman at 9:03 AM on January 29, 2018 [1 favorite]

Yay for good news!
posted by Secretariat at 9:14 AM on January 29, 2018 [1 favorite]

but the attempt to avoid those human rights abuses is precisely why medicine can be slow

corporate, profit-driven medical research has been bucking against regulatory controls like an untamed animal, sometimes successfully enough to to throw off its riders. so I agree that the attempt is there and the effort to stymie abuse is not usually coming from inhouse and the argument against those controls are exactly that it slows down research
posted by runt at 9:19 AM on January 29, 2018 [1 favorite]

not as infrequent as you might imagine:- just in orthopedics

Early Termination of Randomized Clinical Trials in Orthopaedics (PDF Download Available). Available from: [accessed Jan 29 2018].

1) Insufficient recruitment: This is when there is an inability to recruit enough patients;
2) Unforeseen adverse effects:This is when adverse effects that areencountered are of extreme severity andnecessitate treatment abandonment;
3) Futility: This is when interim analysis indicates that reaching the planned sample size to obtain a significant difference between groups is improbable or would demand excessive resources, time,and effort;
4) Apparent benefit or early superiority: This is when, in an interim data analysis, a superior treatment is identified, and the study is ended with an aim to minimize the number of patients who will be denied of the superior treatment;
5) Redundancy: This is when otherstudies are published with results thatmake the current RCT unnecessary; and
6) Funding abandonment:
posted by Wilder at 9:52 AM on January 29, 2018

Yes, thrombectomy is very very new. I remember being shown one of the early devices when I was in medical school. It was basically a corkscrew that the interventional radiologist had to thread (very carefully!) up a hair-sized artery in order to pull out the clot the way you'd pull a stubborn cork. The Trevo, the device used in the DAWN trial, is maybe a few years old and is more sophisticated, easier to handle, less operator-dependent. I have no doubt that they'll get even better as technology advances.

I'm really excited about this because it will totally change our management of "wake-up stroke." Our time clock for stroke starts at the Last Known Normal (not "stroke onset" because unless you literally witnessed someone's face sag, you have no way of knowing when that artery got clogged). So for people with wake-up stroke, we were really stuck. We knew their actual onset was sometime between bedtime and whenever they woke up, but we had no way of quantifying how much brain we could still save. It was a dilemma -- do you give tPA anyway

The reason why the time window used to be 6 hours is that our technology was simply not good enough for longer windows. People had worse outcomes if you thrombectomized at 10 or 12 or 16 or 24 hours -- with time, more tissue becomes irreversibly dead, and before the advent of CT-perfusion (an imaging modality that was only developed in the last couple years) we had no way to tell who had brain left to save, and who was at risk of reperfusion injury, aka bleeding into the dead tissue. The risk of harm outweighed the potential benefit, so we had to figure out a better way to triage that shadowy "maybe" group. The one technology couldn't have happened without the other. fshgrl, remember that rapid roll-out of treatment without scientific rigor leads to problems like thalidomide.

It's also worth keeping in mind that just because a large multicenter trial shows excellent and exciting results, that doesn't mean that this treatment is going to be available to everyone tomorrow. I wish it were! But in order to do this sort of thing, you need 24/7 staffing of an interventional neuroradiology suite, including multiple physicians, nurses, and techs. A lot of smaller community hospitals are not going to be able to handle that. I hope that telestrokes can help identify people who would be good candidates for this and get them stat transferred to stroke centers. I know researchers who are working on rolling out mobile telestroke units in ambulances, so that people can be triaged quickly and minimize treatment delays. I have been on the receiving end of these transfers; there are a lot of moving parts, but when they go well, it's beautiful.

And yes, this should absolutely not make anyone delay if they even suspect they are maybe possibly having a stroke. Every 15 minutes of delay in treatment means you lose a month of healthy life (this is tPA, or the clot-busting drug, but the thrombectomy numbers are similar). Every minute means almost 2 million neurons that aren't coming back. Remember, folks, time == brain.
posted by basalganglia at 4:15 PM on January 29, 2018 [14 favorites]