So instead of increasing the pool of stroke patients being treated we are subjected to lucky candidates with lesser damage being treated better. That is not the correct goal. Our stroke associations should have the goal of 100% recovery for all. Not just the lucky ones.
http://dgnews.docguide.com/mri-based-screening-improves-assignment-patients-stroke-endovascular-treatment?
A system developed for determining which patients with severe strokes
are most likely to benefit from catheter-based systems for blood clot
removal can lead to a greater percentage of screened patients receiving
treatment and to outcomes similar to recent studies that found
significant treatment benefits.
In a study published online by JAMA Neurology, researchers report how
the precision of their classification system, which combines diffusion
magnetic resonance imaging (MRI) with key clinical characteristics, more
than doubled the percentage of screened patients who were assigned to
and probably benefited from treatment.
“Endovascular therapy has been proven to be effective and superior to
other approaches for the treatment of severe strokes caused by the
blockage of large brain arteries,” said senior author Gilberto González,
MD, Department of Radiology, Massachusetts General Hospital, Boston,
Massachusetts. “The critical question has been how to optimise its use
to benefit the most patients while minimising any harm. It appears [our]
approach to patient selection is superior to other approaches and may
be the optimal approach.”
“Our work shows that MRI identifies patients with greater precision,
which means that fewer patients are inaccurately excluded from a
treatment that might otherwise benefit them,” said lead author Thabele
Leslie-Mazwi, MD, Massachusetts General Hospital. “As endovascular
therapy expands at a regional, national and international level, we
think this precision will be essential to providing the most
personalised and cost-effective care.”
The past year has seen an almost complete turnaround for endovascular
treatment, with major clinical trials in several countries reporting
that use of the most sophisticated clot-removing devices -- often in
combination with tissue plasminogen activator (tPA) -- led to
significant recovery in 33% to 70% of patients with major stokes if
treatment was initiated within 6 hours of symptom onset. The studies
achieving the best outcomes used several advanced computed tomography
(CT)-based imaging techniques for patient selection. In contrast, the
researchers at Mass Gen primarily used diffusion-weighted MRI because it
produces the most precise estimate of the size of the ischemic core.
The researchers analysed treatment results for all patients receiving
endovascular therapy at Mass Gen from 2012 through 2014 for acute
strokes caused by blockage of 1 of 2 major arteries within the brain,
along with a subset of patients who did not receive endovascular
treatment because it was determined to have little or no potential
benefit for them.
The research team had previously developed a system for classifying
patients as likely, uncertain or unlikely to benefit from treatment
based on their age, time from symptom onset, size of the clot and the
blocked artery, other health issues, and the size of the ischemic core,
as determined by MRI. The current study also included a group of
patients who received endovascular treatment after CT scanning only,
either because they were unable to receive MRI or for other reasons.
Among 103 patients who received endovascular therapy during the study
period, 72 were screened with diffusion MRI, leading to 40 being
classified as likely to benefit and 32 for whom benefit was uncertain.
Three months after treatment, 52% of the likely-to-benefit group had a
favourable outcome, defined as a return to complete functional
independence, a result achieved by 32% of the uncertain-to-benefit group
and 31% of those evaluated by CT only.
Results were even better in the likely-to-benefit patients for whom
treatment restored circulation to tissue around the ischemic core, with
favourable outcomes in 74%. None of the patients classified as unlikely
to benefit had favourable outcomes.
“The next frontier to investigate is treatment 6 to 24 hours after
stroke onset,” said co-author Joshua Hirsch, MD, Massachusetts General
Hospital. “Data we have accumulated over the past decade suggests that
many patients may be successfully treated at this late stage, and MRI is
the most powerful means to accurately identify these individuals. If
that is true, there may be time to transfer patients who first present
at regional hospitals to centres like the Mass Gen that have the
capability to conduct this type of screening program. While diffusion
MRI is broadly available, only a few major institutions have recognised
its critical role and made it available around the clock in emergent
fashion for the evaluation of severe stroke patients.”
SOURCE: Massachusetts General Hospital
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