In our April issue, we published “Time to Expand Stroke Treatment Window?: Pushing the Envelope for Mechanical Thrombectomy” by Alexei Wagner, MD, MBA; and Sam Shen, MD, MBA, which reviewed Stanford University’s novel Stroke Code Extended protocol, and we invited readers to weigh in on the protocol. Here are some of those responses:

While I commend Dr. Wagner and Dr. Shen for their enthusiasm regarding thrombectomy in strokes, I tend to be a “big picture” kind of person, and the lack of perspective in their article is striking.

First, their assertion that many EPs have felt a certain satisfaction in “saving” stroke victims from a lifetime of debilitating deficits is not shared by a large number of my colleagues who have not witnessed such dramatic saves, and in either case, such anecdotes are not data as to the efficacy of thrombolysis. (NINDS has never been repeated).

Second, raising patients’ and their families’ expectations that there is a “miracle cure” for stroke does no one any good.

Third, the authors fail to point out how few stroke victims are candidates for thrombectomy compared to the total number of strokes. Likewise, data exist that more than half of all patients, thought to be good candidates, transferred for thrombectomy don’t get the advanced treatment.

Finally, as a corollary to point three, how do our scarce resources get used for a treatment designed to help just a few people? I’m thinking in particular of rearranging the entire EMS system so that a few patients get routed to the comprehensive stroke centers.

I want the tertiary care centers to continue their research into stroke treatments so that, in the future, we may have a better idea as to who may benefit from advanced therapies. But until we know who benefits and under what circumstances, I suggest we don’t get ahead of ourselves.

–Jonathan D. Lawrence, MD, FACEP
Long Beach, California

“…many emergency physicians can attest to the professional satisfaction of successfully administering treatment to a patient who otherwise would have had a lifelong, debilitating neurologic deficit …”

Many EM docs have also had a patient presenting with significant deficits who got better before thrombolysis could be initiated. If we got the tPA in fast enough, we would have thought we did a wonderful thing. But that’s why we have double-blind trials. NINDS didn’t show a short-term benefit. The benefit shown was at three months, a time frame beyond the follow-up for most EM docs.