ABLEnews Extra

         TPA: Two-Edged Sword in Stroke Treatment
          
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CHARLESTON, S.C. (AP)--For the first time, a study has shown that it's
possible to reduce the damage strokes cause.
   
But experts aren't yet ready to recommend it for widespread use because
the treatment involves a perilous balance between risks and benefits.
   
The medicine is tissue plasminogen activator--TPA--a genetically
engineered protein that is already a mainstay of heart attack therapy.
   
About 500,000 Americans suffer strokes annually. They are the leading
source of adult disability and the No. 3 cause of death after heart
disease and cancer. Until now, there has been no proven treatment to
limit the damage in the first hours after they occur.
   
A European team reported Friday that TPA significantly reduces the
amount of brain injury resulting from strokes if given quickly after the
onset of symptoms--but only when reserved for a carefully selected
group of patients, probably half to three-quarters of all stroke
victims.
   
The difficulty of deciding precisely who these patients are is likely to
curtail its widespread use, at least until experts sort out better
guidelines for emergency-room doctors.
   
The dilemma for doctors is simple: If given to the right patients, TPA
can prevent a lifetime of paralysis and other crippling disabilities. If
given to the wrong ones, it can trigger bleeding in the brain that makes
the strokes even worse.
   
"The patients who we really want to treat benefit a lot. Treating those
who we don't want to can be a disaster," said Dr. Werner Hacke of the
University of Heidelberg in Germany, the study's director.
   
The study was conducted on 620 stroke patients who were given TPA within
six hours of the start of their symptoms. The results were released at a
stroke conference sponsored by the American Heart Association.
   
Most strokes occur when a blood clot lodges in the brain, cutting off
circulation. However, about 20 percent result when a blood vessel
bursts. TPA is a natural protein that works by dissolving clots.
   
In their study, the doctors intended to treat only those whose strokes
resulted from clots. They performed CT scans first and excluded patients
whose strokes had already resulted in large areas of dying brain tissue.
   
When they looked at the 511 patients who met these criteria, TPA was
clearly beneficial. While their death rate was about the same, they
suffered less brain damage. Forty-one percent of them suffered little or
no lingering effects from their strokes, compared with 29 percent who
got dummy injections.
   
However, it turned out later than 109 patients had been let into the
study by mistake. Most of them already had large areas of damaged brain
tissue. And for them, TPA was more dangerous.
   
Thirty-five percent of these patients who unintentionally got TPA died,
compared with 21 percent with equally severe disease who were not
treated.
   
The European study was financed by TPA's European maker, Boehringer
Ingelheim. It was performed by doctors at 75 hospitals in 14 European
countries.
   
"It's not a home run. The question is whether it's a double or a
single," commented Dr. David Sherman of the University of Texas in San
Antonio.
   
Dr. James Grotta of the University of Texas in Houston, who is
participating in a similar U.S. study, said he believes TPA eventually
will become a routine therapy for strokes.
   
"This is extremely encouraging," Grotta said. "It is a giant step,
although we cannot at this point recommend this drug for everyone with
stroke."
   
Grotta said the U.S. study may show more clear-cut benefits of TPA,
since patients are treated sooner after their symptoms begin, half of
them within 90 minutes. That study, sponsored by the U.S. National
Institutes of Health, is scheduled to be released in May.
   
Three other studies presented at the conference underscore the
difficulty of using clot-dissolving drugs. The studies--two in Europe
and one in Australia--involved a similar medicine called streptokinase.
All three were halted early because of higher death rates among the
treated patients.

[Study First to Show Stroke Treatment Is Possible, Daniel Haney, AP,
February 10, 1995]

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