Journal of Invasive Cardiology

Doug Cavaye: I am a vascular surgeon. My intervention work ends in the carotid artery. I have jotted down some comments which all happen to start with the letter “p.” The first “p” represents the concept of a neurological penumbra — an area of ischemic or dying brain cells that are electrically negative and that may or may not be able to be rescued. Thus, the concept of a penumbra implies that time is very important. If a patient has a deficit that lasts for 60 minutes, my understanding of the literature is that he has about a one in four chance of rescue. If the deficit is present at two hours, the patient has a less than 10% chance of the event being a transient ischemic attack. In other words, a stroke is established in more than 90% of patients at two hours post-event. Thus, getting a patient to the hospital — which is the second “p” for protocol — is just as important as the penumbra. The third “p” is for perforators, which are deadly little arteries. You can’t blow up a balloon 2 cm long in intracerebral vessels without getting a perforator, and it is difficult to predict the occlusion’s locality. A perforator occlusion is dramatic and disastrous. The final “p” — for pharmacology — is something we have not yet discussed. Many of the cardiological improvements, or rescues of cardiac interventions, have relied on pharmacology — whether these are anticoagulants, lytic agents, or anti-spasmodics. What is the current situation with intracerebral or neurological pharmacologic rescue? From what I understand, very few agents are effective.