http://www.frontiersin.org/Journal/10.3389/fneur.2013.00164/full?utm_source=newsletter&utm_medium=email&utm_campaign=Neurology-w46-2013
Aaron P. Tansy and David S. Liebeskind*
- Department of Neurology, UCLA Stroke Center, University of California, Los Angeles, CA, USA
Despite the advent of and exciting advances in novel
endovascular therapies, t-PA remains the only proven treatment for acute
ischemic stroke to date. Although a variety of reasons likely underlie
why past trials of endovascular strategies have been unsuccessful, we
address in this perspective piece one critical unknown for which a
solution is undoubtedly necessary if future ones are to meet with
success: determination and selection of patients that are “just right”
for endovascular treatments, or the Goldilocks dilemma. Key clinical
criteria highlighted in past trials may help provide a solution to this
critical problem. However, for them to do so, we propose that they must
be applied in service of a model that accounts for the nuanced, dynamic
nature of acute ischemic stroke better than the prevailing “time is
brain” model. We provide and examine three clinical cases to illustrate
this proposal towards solving the Goldilocks dilemma and advancing
treatment in acute ischemic stroke. Further, we address our field’s
ongoing challenge and mission in the meantime to best care for the
“not-so-right” patients, by far the majority of the affected stroke
population.
The introduction of intravenous tissue plasminogen
activator (t-PA) heralded a sea change in the management of acute
ischemic stroke (AIS). For the first time ever, a medical therapy for
acute stroke was proven effective in reducing long-term impairment (1).
Since that landmark event nearly two decades ago, the AIS field has
witnessed the exciting development of novel endovascular strategies and
heightened hopes of potentially improving upon t-PA’s clinical efficacy (2–7).
The Goldilocks dilemma, or finding the ideal patient who is “just
right,” remains the most formidable challenge in establishing new
therapies for AIS.
Unfortunately, as of yet, no endovascular method has
demonstrated itself more clinically effective than t-PA either in
head-to-head comparison or in combination with it (5–7).
Why is this? This question is an undoubtedly challenging and complex
one, but also an undoubtedly necessary one to answer. Indeed, continued
progress in AIS treatment and any potential role that endovascular
methods may play in it rests in the balance. We address the Goldilocks
dilemma as a key unsolved piece of this larger problem that has already
received a great deal of attention in the stroke community: identifying
the ideal patients and enrolling them in clinical trials seeking to
prove efficacy of endovascular treatments.
The recent disappointing outcomes in related trials
are a reflection not necessarily of flawed endovascular therapies, but,
rather, of flawed selection of candidates likely to benefit from them.
We also propose that improvement of the theoretical framework of
ischemic stroke on which the criteria for determination of “just right”
trial-eligibility is based may allow future trials to finally achieve
success. Finally, we emphasize that, although our Goldilocks search for
the “just right” acute stroke patient is necessary for future
improvement in care, we must not be distracted and neglect our primary
mission to care for all stroke patients including those “not-so-right” –
by far, the vast majority for whom we neurointensivists and
neurohospitalists currently provide acute stroke care.
More at link.
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