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On Strokes, Doctors Decide for Patients, Even When Patient's Family Knows More



(p. D1) It was one of those findings that would change medicine, Dr. Christopher Lewandowski thought.

For years, doctors had tried -- and failed -- to find a treatment that would preserve the brains of stroke patients. The task was beginning to seem hopeless: Once a clot blocked a blood vessel supplying the brain, its cells quickly began to die. Patients and their families could only pray that the damage would not be too extensive.

But then a large federal clinical trial proved that a so-called clot-buster drug, tissue plasminogen activator (T.P.A.), could prevent brain injury after a stroke by opening up the blocked vessel. Dr. Lewandowski, an emergency medicine physician at Henry Ford Health System in Detroit and the trial's principal investigator, was ecstatic.

"We felt the data was so strong we didn't have to explain it" in the published report, he said.

He was wrong. That groundbreaking clinical trial concluded 22 years ago, yet Dr. Lewandowski and others are still trying to explain the data to a powerful contingent of doubters.

The skeptics teach medical students that T.P.A.is dangerous, causing brain hemorrhages, and that the studies that found a benefit were deeply flawed. Better to just let a stroke run its course, they say.

It's a perspective with real-world consequences. Close to 700,000 patients have strokes caused by blood clots each year and could be helped by T.P.A. Yet up to 30 percent of stroke victims who arrive at hospitals on time and are perfect candidates for the clot-buster do not receive it.

The result: paralysis and muscle weakness; impaired cognition, speech or vision; emotional and behavioral dysfunction; and many other permanent neurological injuries.

Stroke treatment guidelines issued by the American Heart Association and the American Stroke Association strongly endorse T.P.A. for patients after they've been properly evaluated. But treatment must start within three hours (in some cases, four(p. D4)-and-a-half hours) of the stroke's onset, and the sooner, the better.

A number of medical societies also endorse the treatment as highly effective in reducing disability. The drug can cause or exacerbate cerebral hemorrhage, or bleeding in the brain -- a real risk. But in most stroke patients it prevents brain injury, and in any event, rates of cerebral hemorrhage have declined as doctors have gained experience over the years.


. . .


About a decade ago, Dr. Lewandowski was at work when he got a call that his father had had a stroke -- his right side was paralyzed. But his father had gotten to the hospital within 45 minutes, well inside the window to receive T.P.A.

Dr. Lewandowski told his mother to make the family's wishes very clear. They wanted the emergency room doctor to give the clot-buster to his dad. The doctor refused.

"He told my mom that he doesn't believe in the drug and he is not giving it. He doesn't care who I am," Dr. Lewandowski said.

"I got in my car and drove 400 miles to the hospital," he recalled. But by the time he got there, it was too late. The treatment window had closed.

His father had a facial droop and slurred speech. His right arm and right leg flopped about uselessly. His stroke scale was 7, moderately disabling, but he survived for a few more years.

"It was very difficult for me personally," Dr. Lewandowski recalled. "I had spent so much of my professional life working on this treatment. It actually worked."

"I felt like I had let my dad down."



For the full story, see:


GINA KOLATA. "A Stroke Treatment Mired in Controversy." The New York Times (Tuesday, March 27, 2018): D1 & D4.

(Note: ellipsis added.)

(Note: the online version of the story has the date MARCH 26, 2018, and has the title "For Many Strokes, There's an Effective Treatment. Why Aren't Some Doctors Offering It?")






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