Great points you make. But the field isn't really "dying" is it? You mean (I'm guessing) that there isn't as great a need for a huge number of specialists in this field based on disheartening study results? In that case, I would agree with you.
Well, dying might be hyperbole. But outside a few certain things, the indications seem to be drying up.
I've been on call this week, and I've never obtained MRA/CTA's on first time strokes. Given recent data, when would you ever do it? I'm scratching my head.
But as far as acute stroke therapy, what of IMS-I and IMS-II? And the jury is still out on IMS-III, as Strokeguy pointed out.
I predict the numbers are going to be modest. Regardless, some get better, some die, CT perfusion is bull****. When we get cold hard numbers, it's going to look much less attractive for the 85 yo nursing home patients who are found face down in their porridge with a right HP and who's neurotic daughters are >500 miles away.
Lets put it plain and simple, you do not send mild strokes to the angiosuite. These are always patients with bad deficits; more the ICA/M1 or basilar artery occlusions. These are more likely to have poor outcomes. It would be extremely uncommon for these strokes to have an mRS 0-1 at 90 days. If such a miracle cure were possible then the Nobel prize would have been awarded by now. I do see a large volume of these apart from milder strokes as well as TPA responders and non-responders. In addition I do also see several pts with mortality and malignant conversion. No one is justifying sending a mild stroke or a pt who has improved significantly to the angiosuite just to clean an MCA branch.
This is precisely the problem with interventionism. You speak with absolute certainty, "no one is justifying..." but you have no data to back up your assertions. In point of fact, because there is no data, people are doing just that.
Also, I have recently seen Rankin 1 at 3 months after whopper right MCA occlusion. I also have a guy who's the equivalent of a cop who presented with NIHSS 19, aphasic adn right HP. He was low 30's, given IV tPA only, and now works without dysfunction. And more.
The problem is that everyone has these stories. Stories are not data. They're just stories.
Sure I do see complications, but they are not as frequent as they have been made out to be. The number of published trials (registered in clinical trials.gov) also make this case. These trials are not hiding complications and have DSMBs. If this were the case, many of these trials would have been stopped by the NIH. I am talking of trials starting from PROACT, IMS 1&11, EMS bridging, Merci/Multi-Merci (and many others abroad) that have been completed and eventually led to current ongoing phase 3 trials as IMS-3 and MR-RESCUE (that are now ongoing for several yrs). INR trials have also been conducted in non-ischemic pathologies. It is quite clear that these therapies need to be performed at larger institutions either academic or non-academic. There is a reason why we are moving toward telemedicine stroke care to be able to concentrate highly specialized care in experienced hands. These centers have neurovascular teams comprising neurologists, nsurgeons, radiologists, interventionalists, neurointensivists,
that treat a significant number of pts and have specialized roles. Tertiary neurologic care is moving away from the OSH where a demented 85 yr old could get stented for all the wrong reasons. It is very well known that complications are higher in low volume centers. The same is true for all critical fields incl trauma, cardiac, transplant
If you cannot score a home run, it doesnt mean the bat is no good, just that you dont know how to hit.
You're human, so you're blind to small differences in outcomes. You're not blinded. You're biased. None of what you write means anything. You need to get blinded, placebo controlled numbers.
I do not blame neglect for being cautious/suspicious about iatrogenic injuries, but a lot depends on the pt volume and operator expertise (which also depends on how much you do).
Emotional bolstering. You don't "blame" me for caution? Are you joking? Could you possibly be any more condescending? It's OK, I don't blame you and your attendings for being gung ho about experimental procedures that are killing people. After all, I'm sure they have a mortgage and a nice car.
Also, you don't know me, so please don't pretend you do. I've made no secret that I'm not at a high level academic center - but I have been and frankly our volumes are higher.
Being at one of those telemedicine referral centers, and seeing a lot of nuanced and complicated stroke cases, I have some doubts that we will ever be able to get the final word on some of these therapies from an evidence-based standpoint.
Appeal to ignorance. A bit unbecoming.