Background: Dealing with a patient in status epilepticus, refractory to treatment with benzodiazepines, can be a sphincter tightening ordeal. While most seizure activity responds to appropriately dosed benzodiazipines, some will not respond. The choice of second line medication has been hotly debated (i.e. Levetiracetam, fosphenytoin, and valproate). One of the key aspects of management of status epilepticus is early termination. The longer the seizure continues, the more likely patients can have cardiac/respiratory complications, brain injury, rhabdomyolysis, hyperkalemia, and acidosis. Thus, prompt termination of seizure activity with second line agents is critical. Despite recent pediatric studies (ConSEPT, ECLIPSE etc) there is limited guidance on the efficacy or safety of second line mediations for status epilepticus....Read More
Important as front line providers to know research and data behind stroke care
Patients eligible for endovascular care are those with large vessel occlusion in the anterior circulation - anterior cerebral artery, middle cerebral artery, distal intracranial carotid artery and they have to have perfusion mismatch (small infarcted core with a large penumbra).
Background: Currently, alteplase is the mainstay of treatment of acute ischemic stroke. Advocates of alteplase suggest that the benefit of alteplase is greatest when given early and declines with increasing time from stroke symptom onset (i.e. time is brain). Therefore, the AHA/ASA guidelines recommend intravenous alteplase within 4.5 hours after stroke onset, which is based on very weak evidence (i.e. NINDS & ECASS III).
Due to weak evidence in support of it’s use and significant patient risks associated with alteplase, it’s use in acute ischemic stroke remains controversial. One of the big issues is that by decreasing the time for evaluation and treatment, there is an increased risk of administrating alteplase to patients presenting with noncerebrovascular conditions that can resemble an acute ischemic stroke (i.e. stroke mimics). This puts patients with no chance of improvement with alteplase at risk for increased mortality and symptomatic ICH. There is some limited data on the safety of alteplase in stroke mimics and this study adds to that knowledge....Read More