E D I T O R I A L
Alvaro Nagib Atallah*
T h e tre a tm e n t a n d p re v e n tio n o f a c u te isc h e m ic stro k e
P
r o te c tin gv a s c u la r o b s tr u c tio nth e b r a in is o b v io u s lyf r o m th e c o n s e q u e n c e sv e r y im p o r ta n t..o f H o w e v e r , h o w to m a n a g e th is is a v e r y c o m p le xta s k . T h r e e r e c e n t s tu d ie s h a v e p r o v id e d e v id e n c e th a t
s h o u ld n o t b e ig n o r e d o r m is in te r p r e te d b y p h y s ic ia n s .I -3
T h e N a tio n a l I n s titu te o f N e u r o lo g ic a l D is o r d e r s a n d
S tr o k e r t- P A S tr o k e S tu d y G r o u p l s h o w s th e r e s u lts o f a
r a n d o m iz e d , c o lla b o r a tiv e p la c e b o - c o n tr o lle d tr ia l. S ix
h u n d r e d a n d tw e n ty - f o u r p a tie n ts w e r e s tu d ie d . T h e
tr e a tm e n t w a s s ta r te d b e f o r e 9 0 ' o f th e s ta r t o f th e s tr o k e
o r b e f o r e 1 8 0 '. P a tie n ts r e c e iv e d r e c o m b in a n t r t- P A
( a lte p la s e ) 0 .9 m g /k g o r p la c e b o . A c a r e f u l n e u r o lo g ic a l
e v a lu a tio n w a s d o n e a t 2 4 h o u r s a n d 3 m o n th s a f te r th e
s tr o k e .
T h e r e w e r e n o s ig n if ic a n t d if f e r e n c e s b e tw e e n th e
g r o u p s a t 2 4 h o u r s a f te r th e s tr o k e . T h e e v a lu a tio n d o n e
a t 3 m o n th s s h o w e d th a t th e r e w e r e m o r e p a tie n ts in th e
tr e a te d g r o u p w ith m in im a l to n o d is a b ility th a n in th e
p la c e b o g r o u p ( 5 0 % v s . 3 8 % p < 0 .0 3 ) .
I n o th e r w o r d s , lo u t o f 8 tr e a te d p a tie n ts w a s s p a r e d
a n e u r o lo g ic a l d is a b ility . O n th e o th e r h a n d , s y m p to m a tic
in tr a c e r e b r a l h a e m o r r h a g e w a s te n tim e s m o r e f r e q u e n t in
th e g r o u p th a t r e c e iv e d r t- P A ( 6 .4 % ) th a n in th e c o n tr o l
( 0 .6 % ) p < 0 .0 0 1 .
A n o th e r s tu d y , L o w - m o le c u la r w e ig h t H e p a r in
( L M W H ) f o r th e T r e a tm e n t o f A c u te I s c h e m ic S tr o k e ,2
c o m p a r e d s u b c u ta n e o u s in je c tio n s o f lo w - m o le c u la r
h e p a r in , 4 1 0 0 a n tif a c to r X a I V o f n a d r o p a r in c a lc iu m in
0 .4 m l o f s o lu tio n e v e r y 1 2 h o u r s ( h ig h e r d o s e ) , L M W H
*
MD, PhD, MSc
Chairman, Department of Internal Medicine, Escola
Paulista de Medicina, Editor, Sao Paulo Medical Journal.
a lte r n a te d w ith p la c e b o ( lo w e r d o s e ) a n d p la c e b o in je c tio n s
e v e r y 1 2 h o u r s , f o r 1 0 d a y s . T h e e v a lu a tio n a t 6 m o n th s
s h o w e d th a t th e tr e a te d g r o u p h a d a lo w e r in c id e n c e r a te
o f p o o r o u tc o m e s , d e a th o r d e p e n d e n c y in d a ily a c tiv itie s ,
4 5 v s . 6 5 % . I n o th e r w o r d s , it w a s n e c e s s a r y to tr e a t 5
p a tie n ts to b e n e f it o n e . E v a lu a tio n s a t 1 0 d a y s d id n o t s h o w
d if f e r e n c e s in d e a th r a te s o r h a e m o r r h a g e tr a n s f o r m a tio n
o f th e c e r e b r a l in f a r c tio n .
T h e M u ltic e n tr e A c u te S tr o k e T r ia l- I ta ly ( M A S T - I )
G r o u p c o m p a r e d th e e f f e c tiv e n e s s o f s tr e p to k in a s e , a s p ir in
a n d a c o m b in a tio n o f b o th f o r th e tr e a tm e n t o f is c h e m ic
s tr o k e . S ix h u n d r e d a n d tw e n ty - tw o p a tie n ts w e r e
r a n d o m iz e d to r e c e iv e I h o u r in f u s io n s o f 1 .5 m D o f
s tr e p to k in a s e a lo n e , th e s a m e d o s e o f s tr e p to k in a s e p lu s
3 0 0 m g o f b u f f e r e d a s p ir in , o r 3 0 0 m g o f a s p ir in a lo n e f o r
1 0 d a y s , o r n o th in g . T h e c a s e f a ta lity r a te w a s h ig h e r in
th e g r o u p s tr e a te d w ith s tr e p to k in a s e a lo n e , o r
s tr e p to k in a s e p lu s a s p ir in , th a n in th e g r o u p th a t r e c e iv e d
o n ly a s p ir in o r n o th in g .
I n s p ite o f a ll th is in f o r m a tio n , m o r e s tu d ie s a r e
n e c e s s a r y to e s ta b lis h s a f e a n d e f f e c tiv e g u id e lin e s f o r th e
tr e a tm e n t o f s c h e m ic s tr o k e . I t a p p e a r s th a t a s p ir in a n d
lo w - m o le c u la r w e ig h t h e p a r in a r e s a f e , b u t n e w s tu d ie s
a r e n e c e s s a r y to c o m p a r e a s p ir in w ith L M W H a n d w ith
r t- P A .
T h is w ill r e q u ir e c o lla b o r a tiv e s tu d ie s , a n d th e n g o o d
r a n d o m iz e d tr ia ls m u s t b e a n a ly z e d a s a w h o le u s in g a
s y s te m a tic r e v ie w . I n te r e s te d r e a d e r s m a y r e f e r to a v e r y
in te r e s tin g c o m m e n ta r y b y L o n g s tr e th in E v id e n c e B a s e d
M e d ic in e .4 A lth o u g h th e b e s t tr e a tm e n t f o r is c h e m ic s tr o k e
it n o t y e t w e ll e s ta b lis h e d , its p r e v e n tio n is m o r e c le a r .
T r e a tm e n t o f a r te r ia l h y p e r te n s io n , p a r tic u la r ly in th e
e ld e r ly ,S a n d th e lo n g s ta n d in g u s e o f lo w - d o s e a s p ir in in
h ig h - r is k p a tie n ts b r in g s b e n e f its .6
I n r e g a r d s to is c h e m ic
s tr o k e , a s u s u a l, p r e v e n tio n is b e tte r th a n tr e a tm e n t.
1292
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