Take Home Points
- 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).
REBEL Core Cast 24.0 – Stroke Update 2019
Click here for Direct Download of Podcast
Brief History of Stroke Care
- 2015 – Suspected stroke: NCHCT, if onset of symptoms < 3-4.5 hours consider thrombolytics
- 2015 – IMS 3, Mr Rescue and Synthesis did not show any benefit to interventional care. Showed potential worse outcomes
- 2015 – MR CLEAN study – showed benefit in large vessel obstruction specifically anterior circulation strokes MCA, ACA and distal intracranial carotid AA. NNT 5 for benefit
- There are 8 subsequent studies looking at the same question, all looking at patients with large vessel occlusions and 7 out of 8 found benefit to interventional therapy.
How did they identify large vessel occlusions
- MR CLEAN used NIHSS scale
- In some of the later studies they switched to perfusion imaging
- The window of time got larger and larger in the studies
Shortcomings of the studies
- All studies stopped early except for MR CLEAN
- The problem with stopping early is that it probably overestimates the benefit of the therapy
- None of the studies were blinded and all industry sponsored
All these studies have been expanding the time window for the intervention. DAWN and DEFUSE 3 trial pushing it back all the way to 24 hours.
2018 AHA/ACC Stroke Guidelines
- NCHCT within 20 minutes of arrival
- If suspicious for large vessel occlusion – order CTA
- If positive finding on CTA – get CT perfusion study or MRI perfusion study
How to identify large vessel occlusion
- NIHSS stroke scale greater than or equal to 6
- VAN score
- Not yet externally validated but good sensitivity and specificity
Take Home Points
- 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).
For More on This Topic Checkout:
- REBEL EM: Does it Take a VAN to Identify Emergent Large Vessel Occlusion (ELVO) in Ischemic Stroke?
- REBEL EM : 2018 Stroke Workflow
- REBEL EM : Endovascular Therapy for Acute Ischemic Stroke: The New Shiny Toy in Stroke Care?
- REBEL EM : Endovascular Therapy for Acute Ischemic Stroke
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
Cite this article as: Anand Swaminathan, "REBEL Core Cast 24.0 – Stroke Update 2019", REBEL EM blog, December 18, 2019. Available at: https://rebelem.com/rebel-core-cast-24-0-stroke-update-2019/.
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Anand Swaminathan
Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
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