Questions and Answers

Like you, I think that a pharmacologic cocktail may be the future. However, I think it is important to think of the treatment paradigm since irreversible damage due to stroke may involve (1) protecting the brain during ischemia, (2) determining whether the stroke is ischemic or hemorrhagic, and (3) protecting against reperfusion injury. ANSWER: Your comment raises a number of important issues. I will only consider a couple of them. (1) Rapid determination of the type of stroke (ischemic or hemorrhagic) is crucial to the in-hospital management of stroke, and will depend on both (a) improvements in pre-hospital triage and (b) quicker diagnostic tests (e.g., CT, which currently takes a minute or less of actual scanning time to image the brain). However, it is likely that we can formulate a “cocktail” that might be safely given in the field by paramedics to patients suffering from either an ischemic or hemorrhagic stroke. (2) Protecting the brain against ongoing ischemic injury vs reperfusion injury will very likely involve two different drug “cocktails.” Timing the initial onset of the stroke may prove to be quite important, i.e., drugs that may be helpful during the first couple of hours may prove to be contraindicated after, say, eight hours. The efficacy of steroids in the acute period following spinal cord injury (but not later) is an example.