If someone comes in at between three and four and half hours, I would generally expect that the hospital’s going to be a little bit more cautious. And the big issue that we worry about with TPA is the risk of bleeding. And we know that essentially the longer we wait after a stroke, the more leaky the blood vessels in the brain can get where the injuries occurred. And so the more careful we have to be about who giving tpa to, uh, so the question comes up then in someone at three to four and a half hours, we’ll give tpa. In the cases that we can’t give tpa to or beyond, sometimes we’ll be willing to consider something called intraarterial treatment or IA TPA or IA treatment. And with this type of treatment, what ends up happening, and this is kind of like when you get with cardiology, a catheter is inserted into the artery in the leg, and a catheter can be brought up all the way into the brain to where the cloud is actually at. And then there are a few different approaches to actually trying to remove that clot. One is with something called the penumbra device where you actually have a little section and a catheter and you actually try to poke the clot, break up the clot and suck it out. Another way to do it something with something called a stent Trevor, where you actually can put the wire through the clot and open up a stent that grabs the clot and then we can pull it out. Or another option is a direct admission of tpa right at the spot where the clots at hoping to break it up. And so generally that’s been felt to be more of an experimental procedure rather than something that’s been proven by randomized controlled data. I would point out that just recently, earlier this month, the first randomized controlled study has come out demonstrating that actually in some cases intraarterial treatment can actually improve outcomes. Lastly, I would point out that with intraarterial treatment, there are certain cases where we know the IV clot-buster, the IV tpa is less effective. This is in cases where there’s a really large clot in the brain. In some of those cases, and we have to be selective and careful. We can actually use intraarterial treatment to try to break up those clots as well. Those are the main treatments. That is the only real treatment in the acute phase of a stroke.
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