September 6, 2018

Background: Despite serious concerns about the role of alteplase in the management of acute ischemic stroke including, but not limited to, significant conflicts of interest, unbalanced baseline patient characteristics, systematic devaluation of contrary data, lack of reproduced benefit and low fragility index, it remains standard care for patients presenting with symptoms of acute ischemic stroke within 3 (or 4.5 depending on system) hours of onset of symptoms. Though the NINDS studies only showed benefit in a specific subgroup of patients, subsequent work has endeavored to expand the target group in a classic example of indication creep. Patients with minor CVA (NIHSS < 5 without disabling features or, essentially mRS 0-1) represent one such subgroup in which alteplase is often not employed due mainly in part to the perception of minimal benefit with continued potential for harm (i.e. anaphylaxis, intracranial hemorrhage). Alteplase supporters argue that minor stroke patients should still get the drug as it not only may reduce symptoms but can also prevent deterioration. The evidence for this viewpoint is both extremely limited and of poor methodologic quality.

July 30, 2018

Background: Spontaneous, non-traumatic intracerebral hemorrhage, is one of the only stroke subtypes without a proven treatment. It is not as common as ischemic stroke, representing up to 20% of all strokes, but it accounts for almost half of all stroke deaths worldwide.  Furthermore, about a quarter of intracerebral hemorrhage can be complicated by hematoma expansion which can occur up to 24 hours later and is itself associated with poor outcomes.  There have been only small trials looking at the use of tranexamic acid in this group of patients, until now.  The Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2) trial looked to see if intravenous TXA reduces death and dependence when given within 8 hours of spontaneous ICH.

June 4, 2018

Background: Alteplase is a tissue plasminogen activator that is approved for use prior to thrombectomy in ischemic strokes with the goal of reperfusion to ischemic areas of the brain. Tenecteplase is a recombinant enzyme derived from alteplase that is more specific to fibrin and more resistant to inactivation by alteplase inhibitors. Tenecteplase is less expensive, can be administered at a faster rate than alteplase and has a longer half-life allowing for bolus dosing. Prior studies have shown similar to better outcomes with use of tenecteplase versus alteplase in patients with ischemic stroke.

May 31, 2018

Definition: Syndrome characterized by dysfunction of multiple lumbar and sacral nerve roots in the lumbar vertebral canal due to compression


  • The spinal cord terminates in the conus medullaris at the T12/L1 vertebral body in adults
  • Cauda equina
    • Collection of nerve roots from L1-S5
    • Compression from various causes results in lower motor neuron pathology

April 22, 2018

With the publication of the DAWN and DEFUSE-3 trials came a new era in stroke management.  We have discussed the specific literature pertaining to endovascular therapy on REBEL EM before in our 2hour CME activity HERE.  Along with the two new publications came the 2018 AHA/ASA guidelines for endovascular therapy in acute ischemic stroke.  Anand Swaminathan and myself wanted to place a stand alone post on the workflow of stroke in 2018.