Rethinking Acute Management of Stroke: Ryan Radecki

Ryan Radecki urges you to rethink the acute management of stroke.

The current way of thinking about stroke and the acute treatment has been around for decades. In this time, a lot has changed, new technologies have been developed and we have learnt a lot about the underlying physiology of stroke.

Endovascular therapy, CT perfusion, and patient-level predictive modelling are now all at the disposal of clinicians.

Moreover, Ryan wonders if we are using the current treatments – namely tPA – more safely or effectively. In acute stroke management there are two key factors to consider. Successful reperfusion and salvageable tissue.

To restore and save brain tissue one must successfully re-perfuse the tissue. The classic method for achieving this is by using tPA.

However, Ryan contends that this is akin to using a sledgehammer to fix a teacup.

It is a dangerous drug, with many risks, and it is not appropriate for all patients. Salvageable tissue is the second key factor. If brain tissue is dead, it stays dead. It does not matter what drug you give.

Evaluating this tissue makes sense. To this end, Ryan believes that new technologies can be better utilised. As he sees it, some of the new advances in stroke care do not recognise the underlying pathophysiology of the problem. They just deliver pre-historic care, faster.

Further, he argues that the new advances do not individualise care. So, what should be done? Ryan explains that perfusion imaging makes sense, as every patient has unique cerebrovascular anatomy.

The goal should not be to give more patients tPA but to give it to patients who have the best risk-benefit ratio. He argues against expanding the treatment population for tPA against rational judgement.

Moreover, the goal should be to tailor evaluation to identify the patients that will benefit from this intervention and to identify patients who should be put onto a different pathway. Aim to individualise care with the available technology and investigations.

Finally, Ryan discusses the clinical trials underway, which may produce zero, subtle, or huge changes in practice.

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