Tag Archives: ictus

Endovascular therapy in Stroke: the 2015 AHA/ASA Updated Guidelines establish new eligibility criteria.

30 Giu

New evidences aroused in treatment of ischemic stroke from early 2015. Large and well conducted trials demonstrated the benefit of endovascular therapy (in association with thrombolysis) on primary clinical endpoints.

MEDEST post on Endovascular Treatment of Ischemic Stroke

Today AHA and ASA  updated the 2013 Stroke Guidelines for the Early Management of Patients With Acute Ischemic Stroke regarding Endovascular Treatment on the basis of this recent evidences.

Let’s resume the recommendations on Endovascular Interventions:

  • Patients who are elegible for intravenous r-tPA should receive r-tPA and in addition endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):
  1. Prestroke modified Ranking Scale score 0 to 1
  2. Acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional medical societies
  3. Causative occlusion of the internal carotid artery or proximal MCA (M1)
  4. Age ≥18 years
  5. NIHSS score of ≥6
  6. ASPECTS of ≥6
  7. Treatment can be initiated (groin puncture) within 6 hours of symptom onset
  • To ensure benefit, reperfusion should be achieved as early as possible and within 6 hours of stroke onset (Class I; Level of Evidence B-R). (Revised from the 2013 guideline); if treatment is initiated beyond 6 hours from symptom onset, the effectiveness of endovascular therapy is uncertain (Class IIb; Level of Evidence C). (New recommendation)
  • The benefits are uncertain, on carefully selected patients with acute ischemic stroke in whom treatment
    can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries. (Class IIb; Level of Evidence C). (New recommendation)
  • Endovascular therapy with stent retrievers may be reasonable for some patients <18 years of age with acute ischemic stroke who have demonstrated large vessel occlusion in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset, but the benefits are not established in this age group (Class IIb; Level of Evidence C). (New recommendation)

Read the full text on AHA/ASA website:

2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment

Read also:

Medscape article: Groups Issue Guidance on Endovascular Repair of Ischemic Stroke (subscription required)

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Time is brain?

13 Apr

On Stroke (an AHA journal) has recently been published a study entitled Stroke Thrombolysis- Save a Minute, Save a Day” in wich the authors concluded that “time is brain”

This is an observational prospective study conducted between 1998 and 2011 on a cohrt of 2258 consecutive stroke patients treated with r-TPA.

The results shown how any minute delay on TPA administration is a day less in the patient’s life.

But I’m skeptical, and to support my skpepticism, here is a post of the king of skeptical blog in emergency medicine: The Skeptical guide to Emergency Medicine:  Thrombolysis for Acute Stroke in wich in wich are well summarized all the trials on TPA in stroke and many other great resources.

This is the wonderful presentation  by Ken MilneTPA-in-CVA-pdf on the argument.

MEDEST you tubeSo are you really sure that the actual evidences at the base of TPA administration for the stroke patients are so evident?

 

 

rt-PA e Stroke: IST-3 l’analisi dei risultati

10 Apr

Stroke 3

L’analisi detagliata dei dati dello studio più potente e promettente sull’uso del trombolitico nello stroke ischemico chiude definitivamente la discussione su uno studio nato per essere conclusivo, ma che ottiene il risultato, non solo di suscitare molti (e decisivi) dubbi, ma anche di scalfire alcune ragionevoli certezze.

Scarica la trascrizione del podcast

Scarica la Cronostoria dei trials sulla trombolisi nello stroke ischemico

Guarda la cronistoria dei trials sulla trombolisi nell’ictus ischemico

Leggi il post sul “pubblication bias”

Referencs:
  1. IST 3 Study The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen
  2. IST 3 analysys 2013
  3. Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts of interest in biomedical research: a systematic review.
    JAMA. 2003;289:454-469.
  4. Lexchin J, Bero LA, Djulbegovic B, et al. Pharmaceutical industry sponsorship and research outcome and quality: systematic review.
    BMJ. 2003;326:1167-1170
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