- A Neurosurgeon's Guide to Stroke Symptoms, Treatment and Prevention
- Focus on awareness, prevention for Men’s Health Week
- How Doctors Think
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- Transient ischemic attack (TIA)
Rapid and accurate diagnosis of the kind of stroke and the exact location of its damage is critical to successful treatment. Technical advances such as digital imaging, microcatheters and other neurointerventional technologies, the use of the operating microscope microsurgery and the surgical laser have made it possible to treat stroke problems that were inoperable a few years ago. Ischemic stroke is treated by removing obstruction and restoring blood flow to the brain. The only U. Food and Drug Administration FDA -approved medication for ischemic stroke is tissue plasminogen activator tPA , which must be administered within a three-hour window from the onset of symptoms to work best.
Unfortunately, only 3- 5 percent of those who suffer a stroke reach the hospital in time to be considered for this treatment, and the actual use of tPA is considerably lower. This medication carries a risk for increased intracranial hemorrhage and is not used for hemorrhagic stroke. Microcatheter-based surgical interventions for stroke may include the use of a small microcatheter, delivered through a larger guiding catheter inserted at the groin through a small incision.
A microguidewire is used to navigate the microcatheter to the site of obstruction in the brain. Thrombolytic medication, such as tPA, can then be administered directly to the occluding thrombus. This kind of treatment, which delivers thrombolytic medication intraarterially, is more specific than IV intravenous tPA and consequently may require significantly lesser dosages of medication. The time limit to implement this type of intervention is also significantly double longer than that for IV TPA.
Generally, only Comprehensive Stroke Care Centers offer this type of treatment. The Merci Retriever, approved in by the FDA, is a corkscrew- shaped device used to help remove blood clots from the arteries of stroke patients. At the neck, a small catheter inside the larger catheter is guided through the arteries into the brain, until it reaches the brain clot. A straight wire inside the small catheter pokes out beyond the clot and automatically coils into a corkscrew shape.
It is pulled back into the clot, the corkscrew spinning and grabbing the clot. A balloon inflates in the neck artery, cutting off blood flow, so the device can pull the clot out of the brain safely. The clot is removed through the catheter with a syringe. Penumbra is also a microcatheter-based system device, which works by an aspiration principle. It was approved by the FDA in Stentriever devices are the newest generation of embolectomy devices for stroke. They are still in an investigative phase but work by breaking up the occluding clot, combined with aspiration or withdrawal.
Medications used to help prevent stroke in high-risk patients especially those who have experienced a previous TIA or ischemic stroke fall into two major categories: anticoagulants and antiplatelet agents. Anticoagulants thin the blood and prevent clotting. Heparin acts quickly and is given intravenously or subcutaneously beneath the skin while a patient is in the hospital. Slower-acting warfarin can be given orally and is used over a longer period. Because these drugs affect the blood's ability to clot, they require close monitoring by a physician.
Antiplatelet drugs prevent platelet aggregation. Platelets are specialized cells in the blood that initiate a healing process. Large numbers of platelets clump together to form a clot, which can sometimes block an artery or break loose, travel through the bloodstream and block a smaller artery. Antiplatelet drugs make platelets less sticky and less likely to form clots, reducing the risk of ischemic stroke in patients who have had TIA or prior ischemic stroke.
Patients will be given either a general or local anesthetic before surgery. In this procedure, the neurosurgeon makes an incision in the carotid artery in the neck and removes the plaque using a dissecting tool. Removing the plaque is accomplished by widening the passageway, which helps to restore normal blood flow. The artery will be repaired with sutures or a graft.
The entire procedure usually takes about two hours. One may experience pain near the incision in the neck and some difficulty swallowing during the first few days after surgery. Most patients are able to go home after one or two days and return to work usually within a month. Patients should avoid driving and limit physical activities for a few weeks after surgery. There are potential complications with carotid endarterectomy surgery, just as there are with any type of surgery. There is a percent risk of stroke following surgery.
Another fairly rare complication is the reblockage of the carotid artery, called restenosis.
This may occur later, especially in cigarette smokers. Numbness in the face or tongue caused by temporary nerve damage is a possibility, but uncommon. This usually clears up in less than one month and most often does not require any treatment. An alternative, newer form of treatment, carotid angioplasty and stenting CAS , shows some promise in patients who may be at too high risk to undergo surgery.
Carotid stenting is a neurointerventional procedure in which a tiny, slender metal-mesh tube is fitted inside the carotid artery to increase the flow of blood blocked by plaques. Access is gained through a small 0. The stent is inserted following a procedure called angioplasty, in which the doctor guides a balloon-tipped catheter into the blocked artery. The balloon is inflated and pressed against the plaque, flattening it and reopening the artery. The stent acts as scaffolding to prevent the artery from collapsing or from closing up again after the procedure is completed.
There are several potential complications of endovascular treatment. The most serious risk from carotid stenting is an embolism caused by a disrupted plaque particle breaking free from the site. This can block an artery in the brain, causing a stroke. These risks are minimized using small filters called embolic protection devices in conjunction with angioplasty and stenting. There is also a slight risk of stroke due to a loose piece of plaque or a blood clot blocking an artery during or right after surgery.
The risks are balanced against the advantages of a shorter occlusion time 10 seconds, as opposed to 30 minutes for endarterectomy , shorter anesthesia and a small leg incision.businesspodden.se/evaluacin-para-la-mejora-de-los-centros.php
A Neurosurgeon's Guide to Stroke Symptoms, Treatment and Prevention
Hyperperfusion, or the sudden increased blood flow through a previously blocked carotid artery and into the arteries of the brain, can cause a hemorrhagic stroke. Other complications include restenosis and short periods of medically treatable reduced blood pressure and heart rate. Hemorrhagic stroke usually requires surgery to relieve intracranial within the skull pressure caused by bleeding. Surgical treatment for hemorrhagic stroke caused by an aneurysm or defective blood vessel can prevent additional strokes.
Surgery may be performed to seal off the defective blood vessel and redirect blood flow to other vessels that supply blood to the same region of the brain. For a patient with a ruptured cerebral aneurysm, surgical elimination of the aneurysm is only the beginning. Both Nissen and David Holmes, a Mayo Clinic cardiologist and also a former ACC president, said that in cases in which patients have had bad responses to medication and persistent, life-altering chest pain, even a short-term reduction of symptoms may justify a stent. Thanks to such guidelines, the frequency of clearly inappropriate stent placement declined significantly between and Still, the latest assessment in more than 1, hospitals across the country concluded that about half of all stent placements in stable patients were either definitely or possibly inappropriate.
For a patient who is having a heart attack, a stent can be life-saving.
Focus on awareness, prevention for Men’s Health Week
On a recent snowy St. Louis morning, Brown gave a grand-rounds lecture to about 80 doctors at Barnes Jewish Hospital. Early in the talk, he showed results from medical tests on the executive he treated, the one who avoided a stent. He then presented data from thousands of patients in randomized controlled trials of stents versus noninvasive treatments, and it showed that stents yielded no benefit for stable patients.
He asked the doctors in the room to raise their hands if they would still send a patient with the same diagnostic findings as the executive for a catheterization, which would almost surely lead to a stent. At least half of the hands in the room went up, some of them sheepishly. Brown expressed surprise at the honesty in the room. In , after a seminal study, the COURAGE trial , showed that stents did not prevent heart attacks or death in stable patients, a trio of doctors at the University of California, San Francisco, conducted minute focus groups with cardiologists to answer that question.
They presented the cardiologists with fictional scenarios of patients who had at least one narrowed artery but no symptoms and asked them if they would recommend a stent. Almost to a person, the cardiologists, including those whose incomes were not tied to tests and procedures, gave the same answers: They said that they were aware of the data but would still send the patient for a stent.
How Doctors Think
The rationalizations in each focus group followed four themes: 1 Cardiologists recalled stories of people dying suddenly—including the highly publicized case of jogging guru Jim Fixx—and feared they would regret it if a patient did not get a stent and then dropped dead. A patient has chest pain, a doctor sees a blockage, how can opening the blockage not make a difference?
Chances are , you or someone in your family has taken medication or undergone a procedure that is bio-plausible but does not work. According to the Centers for Disease Control and Prevention, about one in three American adults have high blood pressure. Blood pressure is a measure of how hard your blood is pushing on the sides of vessels as it moves through your body; the harder the pushing, the more strain on your heart. Atenolol became such a standard treatment that it was used as a reference drug for comparison with other blood-pressure drugs.
In , a Swedish hospital began a trial of more than 9, patients with high blood pressure who were randomly assigned to take either atenolol or a competitor drug that was designed to lower blood pressure for at least four years. The competitor-drug group had fewer deaths than the atenolol group and fewer strokes compared with That odd result prompted a subsequent study, which compared atenolol with sugar pills.
A analysis of clinical trials—including eight randomized controlled trials comprising more than 24, patients—concluded that atenolol did not reduce heart attacks or deaths compared with using no treatment whatsoever; patients on atenolol just had better blood-pressure numbers when they died. The overall picture of beta-blockers is complex. For example, some beta-blockers have been shown clearly to reduce the chance of a stroke or heart attack in patients with heart failure. Still, according to a study in the Journal of the American Medical Association , more than There is some evidence that atenolol might reduce the risk of stroke in young patients, but there is also evidence that it increases the risk of stroke in older patients—and it is older patients who are getting it en masse.
One doctor, Chinh Huynh, a family practitioner in Westminster, California, wrote more than 1, atenolol prescriptions in for patients over 65, making him one of the most prolific prescribers in the country. So really major changes have to be generational. Data compiled by QuintilesIMS, which provides information and technology services to the health-care industry, show that atenolol prescriptions consistently fell by 3 million per year over a recent five-year period.
If that rate holds, atenolol will stop being prescribed in just under two decades since high-quality trials showed that it simply does not work. Just as the cardiovascular system is not a kitchen sink, the musculoskeletal system is not an erector set. Cause and effect is frequently elusive. Consider the knee, that most bedeviling of joints. A meniscus is a crescent-shaped piece of fibrous cartilage that helps stabilize and provide cushioning for the knee joint.
As people age, they often suffer tears in the meniscus that are not from any acute injury. APM is meant to relieve knee pain by cleaning out damaged pieces of a meniscus and shaving the cartilage back to crescent form. This is not a fringe surgery; in recent years , it has been one of the most popular surgical procedures in the hemisphere. And a burgeoning body of evidence says that it does not work for the most common varieties of knee pain. Something like the knee version of the oculostenotic reflex takes hold: A patient comes in with knee pain, and an MRI shows a torn meniscus ; naturally, the patient wants it fixed, and the surgeon wants to fix it and send the patient for physical therapy.
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And patients do get better, just not necessarily from the surgery. A study of patients over 45 conducted in seven hospitals in the United States found that APM followed by physical therapy produced the same results as physical therapy alone for most patients. Another study at two public hospitals and two physical-therapy clinics found the same result two years after treatment. Neither the patients nor the doctors evaluating them knew who had received real surgeries and who was sporting a souvenir scar.
A year later, there was nothing to tell them apart. The sham surgery performed just as well as real surgery. Except that, in the long run, the real surgery may increase the risk of knee osteoarthritis. At least one-third of adults over 50 will show meniscal tears if they get an MRI. But two-thirds of those will have no symptoms whatsoever.
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For those who do have pain, it may be from osteoarthritis , not the meniscus tear. For obvious reasons, placebo-controlled trials of surgeries are difficult to execute. The most important question then is: Why, when the highest level of evidence available contradicts a common practice, does little change? For one, the results of these studies do not prove that the surgery is useless, but rather that it is performed on a huge number of people who are unlikely to get any benefit.
Meniscal tears are as diverse as the human beings they belong to, and even large studies will never capture all the variation that surgeons see; there are compelling real-world results that show the surgery helps certain patients. And patients themselves are part of the problem. According to interviews with surgeons, many patients they see want, or even demand, to be operated upon and will simply shop around until they find a willing doctor. So, what do surgeons do?
None of us are going to be upset with you for doing the surgery. Just do the surgery. Randomized, placebo-controlled trials are the gold standard of medical evidence. But not all RCTs, as they are known, are created equal. Even within the gold standard, well-intentioned practices can muddle a study. In cancer research, a crossover trial often means that patients in the control group, who start on a placebo, are actually given the experimental drug during the study if their disease progresses.
Thus, they are no longer a true control group. The benefit of a crossover trial is that it allows more people with severe disease to try an experimental drug; the disadvantage is the possibility that the study is altered in a manner that obscures the efficacy of the drug being tested. In , on the strength of a crossover trial, Provenge became the first cancer vaccine approved by the FDA. Given the extraordinary difficulty of treating metastatic cancer, and high expectations following the abject failure of other cancer vaccines, the approval of Provenge was greeted with ecstatic enthusiasm.
Three-and-a-half months into the study, the cancers of patients who had received Provenge and those who had received a placebo had advanced similarly. Nonetheless, patients who received Provenge ultimately had a median survival time of about four months longer than those who received the placebo. Because Provenge did not halt tumor growth, many of the patients who began the study on it also started to receive docetaxel, a chemotherapy drug that is well established to treat advanced prostate cancer.
Their cancer continued progressing, and after another delay, many of them also got docetaxel. In the end, fewer patients in the group that started on a placebo received docetaxel, and, when they did, they got it later in the study. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment. The larger issue has nothing to do with Provenge specifically but about the way it gained FDA approval.
Berliner is hoping to expand and improve registries that track large numbers of real-world patients as an additional source of information. Ideally, findings that suggest a therapy works and those that suggest it does not would receive attention commensurate with their scientific rigor, even in the earliest stages of exploration. But academic journals, scientists, and the media all tend to prefer research that concludes that some exciting new treatment does indeed work.
The study was understandably small—just seven subjects—as there are only so many people with electrodes already implanted in their brains. Given the potential impact, an international team led by Joshua Jacobs, a biomedical-engineering professor at Columbia University, set out to replicate the initial finding with a larger sample.
The team took several years and tested 49 subjects, so that their study would give more statistically reliable results. The scientists were rather stunned to find that deep brain stimulation actually impaired spatial memory in their study. It was a disappointing result, but they were encouraged to show that brain stimulation could affect memory at all—a step toward figuring out how to wield such technology—and they felt an obligation to submit it to the NEJM.
That is how science is supposed to work, after all, because failing to publish negative results is recognized to be a massive source of scientific misinformation. Point being, sensitivity in the scientific community to replication problems is at an all-time high. Another reviewer noted that electrodes were placed on most of the subjects differently in the replication study compared with those in the original study.
So Jacobs and his co-authors analyzed results only from patients with the exact same electrode placement as the original study, and the findings were the same. That is, of course, very true, particularly for important journals. Neuron , one of the most prominent neuroscience-specific journals, quickly accepted the paper and published it last month. It did not receive the media fanfare of the original paper—or almost any at all—although The Wall Street Journal did cover it. The same week the paper appeared in Neuron , Columbia University held a daylong symposium to discuss the replication problem in science.
The president of the National Academy of Sciences and the director of the U. Jacobs was in the audience. Jacobs did not find the answer that simple. He found it strange. Many doctors, scientists, patient advocates, and science writers keep track of new developments through premier publications like the NEJM. The less publicly a shaky scientific finding is challenged, the more likely it becomes entrenched common knowledge. Of course , myriad medical innovations improve and save lives, but even as scientists push the cutting edge and expense of medicine, the National Center for Health Statistics reported last month that American life expectancy dropped , slightly.
There is, though, something that does powerfully and assuredly bolster life expectancy: sustained public-health initiatives. Medicine can be like wine: Expense is sometimes a false signal of quality. On an epochal scale, even the greatest triumphs of modern medicine, like the polio vaccine, had a small impact on human health compared with the impact of better techniques for sanitation and food preservation. Due to smoking and poor lifestyle habits, lung cancer—which killed almost no Americans in the early 20th century—is today by far the biggest killer among cancers.
Thankfully, public pressure to curb smoking has put lung-cancer deaths in rapid decline since a peak in the s. Deaths from lung cancer should continue to diminish, as they are tightly correlated to smoking rates—but with a year lag; that is, lung cancer deaths will decline 20 years after smoking rates decline. The health problems that most commonly afflict the American public are largely driven by lifestyle habits—smoking, poor nutrition, and lack of physical activity, among others.
In November, a team led by researchers at Massachusetts General Hospital pooled data from tens of thousands of people in four separate health studies from to They found that simple, moderate lifestyle changes dramatically reduced the risk of heart disease, the most prolific killer in the country, responsible for one in every four deaths. Fitting even two of those categories still substantially decreased risk. In August, a report issued by the International Agency for Research on Cancer concluded that obesity is now linked to an extraordinary variety of cancers, from thyroids and ovaries to livers and colons.
At the same time, patients and even doctors themselves are sometimes unsure of just how effective common treatments are, or how to appropriately measure and express such things. Graham Walker, an emergency physician in San Francisco, co-runs a website staffed by doctor volunteers called The NNT that helps doctors and patients understand how impactful drugs are—and often are not.
Transient ischemic attack (TIA)
In almost all popular media , the effects of a drug are reported by relative risk reduction. Hence, the NNT is Suddenly, the trade-off looks grim.
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Now, consider a real and familiar drug: aspirin. For elderly women who take it daily for a year to prevent a first heart attack, aspirin has an estimated NNT of and an NNH of As with most drugs, though, aspirin will not cause anything particularly good or bad for the vast majority of people who take it. They want their work to look more useful, and they genuinely think patients need to take this [drug], and relative risk is more compelling than NNT.
Relative risk is just another way of lying. Even remedies that work extraordinarily well can be less impressive when viewed via NNT. Antibiotics for a sinus infection will resolve symptoms faster in one of 15 people who get them, while one in eight will experience side effects. A meta-analysis of sleep-aid drugs in older adults found that for every 13 people who took a sedative, like Ambien, one had improved sleep—about 25 minutes per night on average—while one in six experienced a negative side effect, with the most serious being increased risk for car accidents.
That was by far the hardest thing for me to conceptually appreciate before I really started looking at studies critically. Historians of public health know that most of the life-expectancy improvements in the last two centuries stem from innovations in sanitation, food storage, quarantines, and so on. The so-called First Public-Health Revolution—from to —saw the biggest lifespan increase, predating antibiotics or modern surgery. Encouragingly, deaths in the United States from all types of cancer since then have been falling. Still, American men have a ways to go to return to s levels.
In , two researchers at Brigham Young University surveyed Americans and found that typical adults attributed about 80 percent of the increase in life expectancy since the mids to modern medicine. It is a loaded claim. Who can argue with a law created in part to bolster cancer research? Medical research is, by nature, an incremental quest for knowledge; initially exploring avenues that quickly become dead ends are a feature, not a bug, in the process.
Hopefully the new law will in fact help speed into existence cures that are effective and long-lived. But one lesson of modern medicine should by now be clear: Ineffective cures can be long-lived, too.