Thrombolytic Therapy for Acute Stroke

363 Pages·2015·13.18 MB·English

by  Patrick D Lyden (eds.)

Patrick D. Lyden
Editor
Thrombolytic Therapy
for Acute Stroke
Third Edition
123
Thrombolytic Therapy for Acute Stroke

Patrick D. Lyden
Editor
Thrombolytic Therapy
for Acute Stroke
Third Edition
Editor
Patrick D. Lyden
Stroke Program
Department of Neurology
Cedars-Sinai Medical Center
Los Angeles , CA , USA
ISBN 978-3-319-07574-7 ISBN 978-3-319-07575-4 (eBook)
DOI 10.1007/978-3-319-07575-4
Springer Cham Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014943240
1st edition: © 2001 Humana Press Inc.
2nd edition: © 2005 Humana Press Inc.
© Springer International Publishing Switzerland 2015
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This book is again dedicated to our families,
who daily cope with the vagaries,
inconveniences, and turmoil surrounding
our involvement in a Stroke Team.
It is also dedicated to the patients
who have volunteered to participate
in the placebo- controlled trials of
thrombolytic stroke therapy in the USA,
Europe, Canada, and Japan: a more
courageous and selfl ess group act,
on such a scale, may not be seen
again in medical research.

Pref ace
This book remains intended for any physician seeking to learn to use thrombolytic
therapy for acute stroke. As in prior editions, we present facts and data for you to
consider while segregating our opinions clearly apart from the facts. For this third
edition we updated many chapters extensively and added sections pertaining to new
technology. Notably, some of the leading champions of stroke MRI updated a key
chapter that hopefully will point us toward improved patient selection. For a while
longer, CT will remain the most widely available imaging procedure, and Professor
Rudiger von Kummer extensively revised this important chapter as well.
C areful patient selection remains the trick, and all chapters describing the back-
ground, use, and nuance of thrombolytic therapy were revised. Everything you need
to know is provided: rationale, preclinical trials, early trials, and pivotal trials.
Practical how-to chapters guide you in treating acute stroke patients, with or with-
out thrombolytic therapy. To enable the reader to practice the knowledge gained, we
added new case scenarios in an interactive format. Unique, I think, among stroke
therapy books, this practice case section will allow you to utilize all the facts and
advice contained in the remainder of the book. Work the scenarios, and you will be
as ready as you can be for your fi rst case.
The history of thrombolytic therapy for stroke makes for remarkable reading and
I recommend a memoir by Dr. Justin Zivin, with John Simmons, for profound
insights into the back-story1 . Initially, thrombolysis in humans caused disasters, but
no one knew going in that the risks were so high. Following those horrible results,
nearly 20 years passed before the medical community again attempted thrombolytic
therapy in stroke. That Greg del Zoppo, Justin Zivin, and especially John Marler
were able to inspire the large, randomized trials of the early 1990s, based on critical
animal experiments, should impress us all.
S adly, today thrombolytic therapy stands alone as the single successful stroke
therapy of our generation. Encouragingly, we fi nally have begun to move beyond
the prediction that thrombolytic therapy can be used only in specialized centers full
1 t -PA for Stroke: The Story of a Controversial Drug. Justin A. Zivin and John Galbraith Simmons.
December 2010. Oxford University Press, USA.
vii
viii PPrreeffaaccee
of “commandos” willing to take call and respond to Code Stroke calls on a moment’s
notice. Stroke patients now receive thrombolytic therapy in a variety of venues and
from a wide range of physicians, including emergency, internal, and family medi-
cine practitioners. In the USA, the Joint Commission certifi es Primary and
Comprehensive Stroke Centers, fulfi lling a fanciful prediction some of us made—
half joking—during the years we sought to roll out thrombolytic therapy for acute
stroke to a wide audience. Today it is as true as it ever was, however, that expertise
and dedication to learning the protocol are required.
The personal toll the original NINDS trial exacted from the authors—my friends
and colleagues—has become legend in clinical neurology. In some ways the leg-
ends both underplay and overstate the struggle we endured. Yes there were divorces,
neglected children, and wild, high-speed rides through red lights and across freeway
medians, but no story—told in the comfort of a classroom or a seminar hall—can
possibly recreate the sensation that comes while injecting irretrievably a bolus of
potentially fatal thrombolytic into a patient you met about 20 min ago. The impor-
tant point, to me, is that in many centers thrombolytic stroke therapy is now routine,
as integrated in the daily functions of the medical center as Code Blue or cardiac
transplantation. Getting us to this point required creativity, sacrifi ce, extreme effort,
and in some cases heroism. The hard job is done now, and the task remains to dif-
fuse the knowledge throughout the medical profession and in public: too few
patients receive good stroke care, and during the time it took to read this Preface, 2
more patients in the USA suffered disabling strokes.
Thrombolytic therapy for stroke reduces disability; time is brain my friends, and
the clock is ticking.
Los Angeles, CA, USA Patrick D. Lyden, M.D.
Acknowledgements
E diting a multi-authored book is a harrowing and gratifying experience, one that
would be impossible without the able and noble efforts of others. I am grateful to
the authors for diligently writing and revising their work in an unheard-of few short
months and the editors at Springer, especially Portia Levasseur and Gregory
Sutorius. My special thanks go to the fellows of the UCSD Stroke Center, for dedi-
cated hard work in implementing the principles of this book for many years during
Code Strokes in San Diego, and to Dr. Justin Zivin, for many years of mentoring.
The nurses on staff at the UCSD and the Cedars-Sinai Stroke Centers, phenome-
nally dedicated to stroke research and patient care, also aided me greatly.
I especially recognize my colleague in managing the NINDS rt-PA for Acute Stroke
Trial and our subsequent multicentered trials, Karen Rapp, a nurse and clinical
researcher of the highest caliber, motivation, and compassion. My deepest gratitude
goes to my daughters Hannah and Hillary who emerged from the “Stroke Code”
years relatively unscathed and to Ms. Laurie Schechter for putting up with me at
home and facilitating the easy completion of this task.
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