Few Stroke Patients Receive Clot-Busting Drug, Study Finds

MILWAUKEE _ Lying in the emergency room with her face drooping, speech slurred, vision blurred and left side paralyzed, Jill Pichler had a quick decision to make.

Did she want doctors to give her a drug that could break up the blockage that was causing her stroke, but that also carried a small risk of causing severe, possibly deadly, bleeding in her brain?

Pichler and her husband, Paul, who was by her side, could not ponder her options for long. For each minute that ticked by, as many as 2 million brain cells probably were dying.

Pichler, 44, who was treated at Waukesha Memorial Hospital last year, was one of the 700,000 people who suffer strokes every year in the United States. But she was among the tiny minority who actually recognize their symptoms soon enough and get to a hospital that offers the clot-dissolving drug t-PA.

A study published Tuesday found that only 2 percent of stroke patients get t-PA, most because they did not get to the hospital in time, but some because doctors simply failed to administer it.

The study in the journal Neurology highlights a growing frustration among stroke specialists. T-PA, which has been available since 1996, can substantially reduce the risk of disability from a stroke, the leading cause of major disability and third leading cause of death in the United States.

But despite years of stroke awareness efforts, the portion of patients who get the drug has not increased appreciably.

“It certainly hasn’t gotten any better,” said co-author Mathew Reeves, an associate professor of epidemiology at Michigan State University.

The study looked at 2,566 stroke patients admitted to 16 hospitals in Michigan.

It found that only 13 percent of them arrived at the hospital within three hours of the onset of their symptoms _ the recommended time window for using t-PA _ as well as meeting other eligibility requirements for the drug.

The finding highlights the lack of public awareness of the signs of a stroke and the inability of patients to get to the hospital immediately, before irreparable damage is done to the brain.

However, the study also pointed to another troubling finding. Even when patients arrive at a hospital within three hours, they still may not get the drug.

The study found that among the 330 patients who met the drug’s eligibility criteria, only 13 percent were treated with it.

“Clearly, the hospitals have to do a much better job of delivering the drug,” Reeves said.

Doctors say people having strokes should go to a hospital with an expertise in treating stroke, provided it does not take appreciably longer to get to one.

Because the blood supply to part of the brain is cut off during a stroke caused by a blockage or clot _ a so-called ischemic stroke _ quick treatment is crucial to surviving with limited disability.

In a typical untreated stroke, 1.2 billion neurons are lost, which is the equivalent of accelerating the normal aging of the brain by 36 years, according to a recent analysis in Stroke, a journal of the American Heart Association.

Viewed another way, an area of brain tissue the size of 1 { ping-pong balls is irretrievably lost.

Several clinical trials have proved the effectiveness of t-PA therapy, especially when the drug is administered early.

A 2004 analysis of six clinical trials involving 2,775 patients, published in the journal The Lancet, found that those who got t-PA within 90 minutes of the onset of their symptoms were 2.8 times more likely to recover than those who got a placebo.

Those treated between 91 minutes and three hours were 1.6 times more likely to recover and those treated between three hours and 4.5 hours were 1.4 times more likely to recover.

However, the risk of substantial bleeding in the brain was 5.9 percent in those treated with t-PA, compared with 1.1 percent of those who got a placebo.

Because of the bleeding risk, some doctors have been reluctant to use the drug.

“If you give it and something goes wrong, you’re damned,” said Varun Saxena, a neurologist at St. Luke’s Medical Center in Milwaukee and co-medical director of its stroke center. “If you don’t give it and something goes wrong, you’re damned.”

Last May, Pichler recognized she might be having a stroke and was able to get to Waukesha Memorial within 40 minutes of the onset of the symptoms.

Pichler said her symptoms hit her “like a ton of bricks. I knew right away I was having a stroke.

“When I was lying there in the emergency room, I said `I’m not ready to go yet. I have to fight. I have so much to accomplish.”’

Within 36 minutes, doctors did a CT scan and found a blockage in her right middle cerebral artery. The scan also helped rule out a bleeding stroke.

Pichler said she and her husband decided she would get t-PA because they knew she would not get any better if they didn’t try something.

Four minutes after the CT scan was completed an intravenous needle was inserted in her arm and t-PA was administered.

Pichler said that within a half hour her symptoms started to abate. Her speech improved and she could move her left side.

Today, she still has some deficit. She walks with slight limp. She has some weakness in her left hand. She gets regular headaches and occasionally experiences a slight amount of confusion.

But, she said, she believes t-PA saved her from having major disability.

“I would not have been able to walk,” she said. “I’m alive and I can still be with my family and friends.”

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STROKE WARNING SIGNS

_Sudden numbness or weakness in face, an arm or leg

_Confusion, trouble speaking or understanding

_Trouble seeing

_Trouble walking, dizziness, loss of balance or coordination

_Severe headache with no known cause

Call 911 if you have these symptoms.

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(c) 2006, Milwaukee Journal Sentinel.

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ARCHIVE GRAPHICS on KRT Direct (from KRT Graphics, 202-383-6064): 20020320 MED STROKE, 20010503 Clot buster

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