http://stroke.ahajournals.org/content/48/12/3413?etoc=
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Neuroprotection
to prevent infarct progression as a potential treatment for acute
ischemic stroke carries a long and disappointing history. The failures
of these prior neuroprotection trials have many potential explanations
that encompass both problems with the preclinical assessment of these
drugs and the design/implementation of clinical trials.1
Prior development of neuroprotection has focused primarily on its use
as a monotherapy, and no clinical trial was designed to determine
whether neuroprotection could extend the time window for successful
reperfusion or ameliorate the consequences of reperfusion. Acute stroke
therapy has now entered the era of highly effective reperfusion with the
recent publication of 5 positive thrombectomy trials.2
Combining neuroprotection with intravenous or intra-arterial
reperfusion therapy is now an important next step in the development of
acute stroke therapies. One approach to neuroprotection would be to
initiate therapy early after ischemic stroke onset, either in the
ambulance or at a primary stroke center/community hospital to
potentially extend the time window for intravenous or intra-arterial
therapy. A second approach would be to use neuroprotection during or
after partial or complete reperfusion to reduce the consequences of
reperfusion injury. Both future neuroprotective approaches will require
preclinical studies that anticipate novel clinical trial designs and
trials that will be organized and evaluated differently than past
monotherapy neuroprotection trials.
Ischemic Penumbra and Core
Acute
ischemic stroke therapy is designed to reduce infarction of
hypoperfused brain tissue and limit the expansion of already
irreversibly injured tissue when treatment is initiated, leading to
smaller infarction and improved clinical outcomes.3,4
Severely hypoperfused but still potentially viable ischemic brain
represents the ischemic penumbra, whereas irreversibly injured tissue is
the ischemic core.5 Early
after stroke onset, most patients with a large vessel occlusion (LVO)
have an extensive ischemic penumbra that can be salvaged by timely
reperfusion. This concept was proven …
Withholding treatment from the control group would be the clearest test of a new treatment BUT WHO WOULD VOLUNTEER FOR THAT?
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