December 18, 2019

REBEL Core Cast 24.0 – Stroke Update 2019

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:

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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