March 18, 2021

Background: The publication of the MR CLEAN trial in January 2015 changed the face of ischemic stroke care. This was the first study demonstrating a benefit to endovascular treatment of a specific subset of ischemic stroke patients: those with a large vessel occlusion (LVO) presenting within 6 hours of symptom onset. MR CLEAN was followed by a flurry of publications seeking to replicate and refine treatment as well as expand the window for treatment. The REBEL EM team reviewed this literature back in 2018 and, with the help of Dr. Evie Marcolini, created a workflow (see CVA Workflow below).

One major component of LVO management is the use of systemic thrombolytics in patients presenting within the current thrombolytic treatment window prior to endovascular intervention. However, it’s unclear if systemic thrombolytic administration results in better outcomes or if it simply exposes the patient to increased risks at a higher cost. Limited evidence questions the utility of the current approach with lytics + endovascular therapy (Phan 2017, Rai 2018).  In 2020, we reviewed an article by Yang and colleagues that demonstrated non-inferiority to an endovascular intervention only approach (with a 20% non-inferiority lower limit) (REBEL EM). Recently, two more studies have been published on this topic.

March 17, 2021

Background: Medicine by press release has been an unfortunate reality of the COVID-19 pandemic.  This is not the standard many physicians would use for medical decision making, but one many of us have had to face; what do I do with the information that is presented with no transparency in the data behind the statements? Despite all the debate and controversy only two treatments for hospitalized patients, have been shown to improve mortality: corticosteroids and IL-6 receptor antagonists (when combined with steroids). Two more treatment options that have been debated throughout the pandemic include convalescent plasma therapy and anticoagulation.  We now have two pre-prints that shed some more light on both of these topics.

March 15, 2021

Shooting azimuths is a critical skill required for accurate land navigation in foreign territory. The steps involved are simple:
  • Ascend to the tallest nearby point with a compass in hand.
  • Select a landmark in the distance.
  • Recalibrate your route toward that landmark.
An azimuth in life could be a goal or project. "Shooting Azimuths" allows us to recalibrate the route towards our goals. But, how do we shoot an azimuth in life?

March 11, 2021

Background: Patients who present with a transient ischemic attack (TIA) are at higher risk of subsequent stroke, especially in the short term (< 7 days). However, the majority of these patients do not experience strokes which leads to a clinical conundrum; should all TIAs be admitted for evaluation? Comprehensive investigation, aggressive treatment, and/or hospital admission is not feasible for all patients and being able to risk stratify these patients to those who would most likely benefit is crucial.