Lest we forget: the other 97%

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  • Lest we forget: theother 97%

    The advent of recombinant tissueplasminogen activator (r-tPA) therapyrevolutionized the treatment of strokefor the lucky few who reach the hospitalin time. Thrombolytic therapy haschanged the treatment of ischemicstroke from a ritualistic to an activeaggressive one. About 15 years ago,the National Institute of NeurologicalDisorders and Stroke (NINDS) trialsinvolving tPA were performed (1)making thrombolytic therapy the stan-dard of care for acute ischemic strokepatients presenting to the hospitalwithin 3 h and, more recently, up to4.5 h of symptom onset (2). Time isbrain and thus billions of dollars havebeen invested to help increase tPAusage. However, therapeutic uptakehas been modest with only about 3%

    of acute ischemic stroke patients indeveloped and 1% in developing coun-tries able to derive the benefit of r-tPA.What happens to the other unfortunate97% to 99%? A visit to the major strokeconferences makes one ponder whetherthis other 97% is getting ignored. Con-ference time is primarily devoted tostudies attempting to increase thetherapeutic window and therapeuticuptake of thrombolytic therapy, emerg-ing mechanical devices, and interven-tional procedures. Minimal conferencetime is devoted to the acute strokepatient who cannot derive the benefit ofthis wonder drug on account of beenexcluded due to some reason witharrival outside the 4.5 h window beingthe most commonly cited reason (3).Core issues of poor compliance ratewith antiplatelet and anticoagulanttherapy, urinary tract, and respiratoryinfections which increase morbidityand mortality are rarely the hot topics.Modification of stroke risk factors andtimely placement of feeding and tra-cheostomy tubes is largely neglected.The goal of medicine should alwaysremain doing the greatest good for thegreatest number of people. The hypeassociated with tPA is not unjustifiedbut the pendulum has swung to the

    other extreme. In a resource-limitedcountry such as India, this approachseems hard to justify. We may or maynot be able to improve tPA utilizationrates further. We can, however, certainlyimprove stroke outcomes in the vastmajority of patients by aggressivelyaddressing the previously mentionedfactors. So for this other 97%, the timehas come to stand up and be heard.

    Prahlad K. Sethi1 andNitin K. Sethi2*

    1Department of Neurology, Sir Ganga RamHospital, New Delhi, India

    2Department of Neurology,New York-Presbyterian Hospital, Weill Cornell

    Medical Center, New York, USA

    References1 The National Institute of Neurological

    Disorders and Stroke rt-PA Stroke StudyGroup. Tissue plasminogen activator foracute ischemic stroke. N Engl J Med 1995;333:15817.

    2 Hacke W, Kaste M, Bluhmki E et al. Throm-bolysis with alteplase 3 to 4.5 hours afteracute ischemic stroke. N Engl J Med 2008;359:131729.

    3 Kwan J, Hand P, Sandercock P. A systematicreview of barriers to delivery of thrombolysisfor acute stroke. Age Ageing 2004; 33:11621.

    Correspondence: Nitin K. Sethi*,New York-Presbyterian Hospital, Weill CornellMedical Center, 525 East 68thStreet, New York,NY 10065, USA.E-mail: sethinitinmd@hotmail.com

    Conflict of interest: none declared.

    DOI: 10.1111/j.1747-4949.2012.00909.x

    Letter to the editor

    2013 The Authors.International Journal of Stroke 2013 World Stroke Organization

    E6 Vol 8, April 2013, E6