CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 3, April 2013
AFRICA
51
Editorial
Acute ischaemic stroke: highlighting the need for early
intervention
If only the brain was like the heart where losing a ‘bit’ from
ischaemia and infarction would have little effect on its function,
the treatment of stroke in the acute setting would not be such a
public health issue. The effects of stroke on an individual and
the burden its leaves on families and society are enormous and
costly.
Stroke remains the third leading cause of death worldwide.
The annual death toll on stroke is reported as being approximately
7.8 million.
1
Despite current treatment options and interventions,
this number is projected to rise and reach almost eight million
in the next 15 years. In developed countries the cost of stroke
treatment ranges from $500–150 000.
2
This wide range is
presumably related to the greater use of mechanical interventions
in some countries as opposed to predominantly pharmaceutical
interventions in others. Unfortunately, in developing countries,
cost estimates are not readily available. The only reported data
comes from Togo where a cost of EUR400 is estimated.
3
Definitive treatment that would completely reverse an
ischaemic event to the brain remains the holy grail of neurology.
In the review by Drs Jivan, Ranchod and Modi, a PUBMED
search and analysis of data on the management of acute
ischaemic stroke (AIS) from 1995 to 2012 is presented. The
interventions described include intravenous recombinant tissue
plasminogen activator (IV r-tPA)-induced thrombolysis, intra-
arterial (IA) thrombolysis and the controversial aspects of clot-
removal treatments.
The conclusions are simple in that the gold standard for
treating AIS remains IV r-tPA. The important facts in this
regard are that the other intravenously administered agents,
including streptokinase, reteplase, urokinase, anistreplase and
staphylokinase, show no benefit and should be avoided in routine
clinical practice.
4
The data on IV r-tPA from the ECASS 3 trial
indicated that for every 100 patients treated in the 3–4.5-hour
window period, 16.4 will have a better outcome and 2.7 will have
a worse outcome.
5
The risk of intracranial haemorrhage was 27
vs 17.6% for placebo.
5
The mortality between the treated and
placebo groups were not significantly different.
The data therefore indicate that the treatment modality is
not ideal and is limited by the 3–4.5-hour window period but
we have nothing better. IA thrombolysis should theoretically be
the better treatment option but strangely, the suggestion in the
literature is that IA thrombolysis in not significantly better than
IV thrombolysis.
6
A conclusive study in this regard is lacking.
With regard to mechanical clot retrieval, the simple answer
is that this is becoming ‘much ado with nothing significantly
attained’. The theoretical concept is appealing and the technical
expertise is available. The results, however, and in particular
with the popular MERCI device, have been disappointing.
The investment in mechanical clot retrieval continues and
newer devices are developing, including a penumbra system,
which disrupts and aspirates the thrombus. This is undergoing
evaluation and is apparently promising. Stent-based therapy and
endovascular angioplasty are also used with varying degrees of
success.
The problem with these devices is that the endpoint of
recanalisation is readily achieved but is not associated with
clinically significant outcomes. The future of this therapeutic
approach therefore remains to be determined.
The conclusions are that for patients with AIS, early
intervention within 4.5 hours with IV r-tPA is the only option
for reversal at present. This needs to become widely used in
the emergency departments of all public and private hospitals
nationally. We must review and recharge the national drive for
public stroke awareness to facilitate this.
GIRISH MODI, MB BCh (Wits), MSc (Lond), PhD (Lond),
FCP (SA), FRCP (Lond)
Department of Neurosciences, School of Clinical Medicine,
Faculty of Health Sciences, University of the Witwatersrand,
Johannesburg, South Africa
References
1.
Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around
the world.
Lancet Neurol
2007;
6
: 182–187.
2.
Luengo-Fernandez R, Gray AM, Rothwell PM. Costs of stroke using
patient-level data: a critical review of the literature.
Strok
e 2009;
40
:
e18–e23.
3.
Guinhouya KM, Tall A, Kombate D, Kumako V, Apetse K, Belo M,
et
al
. [Cost of stroke in Lomé (Togo)].[Article in French].
Sante
2010;
Aug 4. [Epub ahead of print]. Alternate source:
-
medicine.com/medline/ebm/record/20682484/abstract/.
4.
Bryer A, Connor MD, Haug P, Cheyip B, Staub B, Tipping B,
et al
.
South African guideline for management of ischaemic stroke and tran-
sient ischaemic attack 2010: A guideline from the South African Stroke
Society (SASS) and the SASS Writing Committee.
S Afr Med J
2010;
100
(11): 750–778.
5.
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D,
et al
; ECASS investigators. Thrombolysis with alteplase 3 to 4.5 hours
after acute ischemic stroke.
N Engl J Med
2008;
359
(13): 1317–1329.
6.
Powers WJ. Thromobolysis for acute ischaemic stroke: is intra-
arterial better than intravenous? A treatment effects model.
J Stroke
Cerebrovasc Dis
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21
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