Should the severity of ischemic stroke affect your choice of treatment?

In a nutshell neither tPA nor mechanically removing it addresses the neuronal cascade of death. They aren't even asking the right question. The question is: 'What group of actions results in the least amount of dead and damaged neurons?'
http://medivizhat or.com/blog/SampleLibrary/stroke/should-the-severity-of-ischemic-stroke-affect-your-choice-of-treatment/

In a nutshell

This study looked at patients with ischemic stroke and investigated whether removing blood clots via a flexible tube inserted into the artery is only beneficial and safe for patients with less severe strokes. 

Some background

A stroke is a disruption of blood flow to an area in the brain. It can be caused by a blood clot (ischemic stroke) or a ruptured blood vessel (hemorrhagic stroke).
The loss of oxygen supply can result in cell death and brain damage. Immediate treatment is therefore necessary in order to restore blood and oxygen flow.
Treatment for an ischemic stroke can involve intra-arterial therapy. This is where a flexible tube (catheter) is inserted into a blood vessel and moved along the blood system until it reaches the blocked artery. The blood clot is then broken down by releasing drugs (thrombolytic drugs) into the artery or by mechanically removing it via the tube.
However, it is not known whether this approach is only effective in patients with less severe strokes. A type of brain scan, called noncontrast computed tomography (NCCT) is used to determine the size of the brain area that has been deprived of oxygen (called infarcts). A scale of 0-10 determines the size of the affected area, with lower scores having larger infarct areas and greater damage. 

Methods & findings

This study investigated whether intra-arterial treatment is only effective and safe in treating ischemic stroke in patients with an NCCT score of >5 (less severe stroke).
The study included 249 patients with ischemic stroke. All patients underwent an NCCT scan and were divided into 3 groups: 0-4 (large infarcts), 5-7, and 8-10 (smaller infarcts). All patients underwent intra-arterial treatment with thrombolytic drugs.
The study found that patients with higher scores (>5) benefited more from intra-arterial therapy and had higher rates of good outcome (better recovery) and lower rates of mortality, compared to those with lower scores. Rates of good outcome were 5% in the 0-4 group, 38.6% in the 5-7 group, and 46% in the 8-10 group. Mortality rates were 55% in the 0-4 group, 28.9% in the 5-7 group, and 19% in the 8-10 group.
A side effect of intra-arterial therapy is a brain hemorrhage, or brain bleed. The study found that brain hemorrhages were more common among patients with lower scores. It was also found that early treatment resulted in better outcomes only among patients with higher scores.

The bottom line

The study concluded that ischemic stroke patients should receive NCCT scans to determine infarct size and suggest that patients with large infarcts should not receive intra-arterial treatment as it is unlikely to improve patient outcome and increases the risk of hemorrhage.

The fine print

The study only included patients who had a stroke caused by a blood clot in the anterior cerebral artery. 

What’s next?

If you or someone you know are at risk of having a stroke, talk to a doctor about the benfits and risks of intra-arterial therapy and whether treatment should be determined by infarct size. (Yeah, while mostly either non-communicative or unresponsive YOU are supposed to be directing your emergency room doctor into how to treat you. Any more stupid ideas?)