Making dents in steely problems

Last year in an interview, Marc I. Chimowitz, MB, ChB, of the Medical University of South Carolina Stroke Program in Charleston, S.C., said that researchers have “made a dent” in the treatment of patients with intracranial atherosclerotic disease. This group is at high risk of stroke; for instance, stroke patients with severe stenosis treated with medical therapy face a 22 percent risk of recurrence or death the first year after a stroke (N Engl J Med 2005; 352:1305-1316).

That raises the question: how to treat those who don’t respond to medical therapy alone? And are there treatments for events such as intracerebral hemorrhage that offer better outcomes, perhaps at a lower cost, than standard medical care?

Those questions are being pondered this week at the American Stroke Association’s International Stroke Conference in Honolulu. In the first days of presentations, it is clear that stroke remains challenging but that, as Chimowitz advocates, the scientific community is carefully designing and testing alternative therapies for these patients.

Not all approaches prove to be successful, as results from IMS III trial have shown. The Phase III study comparing endovascular therapy after intravenous tissue plasminogen activator (t-PA) with intravenous t-PA alone in patients with moderate to severe ischemic stroke found similar safety outcomes and no significant difference in functional independence.

The trial was terminated for futility. A separate trial that compared endovascular treatment with intravenous t-PA in patients with acute ischemic stroke concluded that “the more invasive and expensive endovascular therapy” was not superior to intravenous thrombolytic therapy.

Some presentations offer rays of hope. One-year results from the MISTIE (Minimally Invasive Surgery plus t-PA for Intracerebral Hemorrhage Evacuation) trial showed an experimental procedure that combines minimally invasive surgery and t-PA to treat patients with intracerebral hemorrhages appears to be safe compared with standard medical therapy. It also showed improved outcomes—with a savings of $44,329 per patient. The results should be viewed with caution, though, because this is a Phase II trial.

Yet another study suggests that some intracerebral hemorrhage patients, if kept on life support, will regain an acceptable level of function over time. The researchers defined acceptable as a modified Rankin Scale score of 4 or less; 4 is deemed a moderately severe disability that requires assistance for walking and attending to bodily functions.  

Please check for more updates as the conference continues.   

Candace Stuart

Cardiovascular Business, editor