14 May 2020

May 14, 2020

Written by REBEL EM

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 (shown 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). There is a clear need for further research into systemic thrombolytics dosing and use.

Medical Categories: Neurology
0 Likes
23 Mar 2020

March 23, 2020

Written by REBEL Reviews

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 team reviewed this literature back in 2018 and, with the help of Dr. Evie Marcolini, created the below workflow:

Medical Categories: Neurology
1 Like
6 Feb 2020

February 6, 2020

Written by REBEL EM
Background Information: The administration of alteplase (tPA) in acute ischemic stroke (AIS) continues to remain a highly debated topic. As hospital systems continue to undergo major changes to facilitate this controversial drug’s administration, more studies are coming out focusing on neuroimaging and how it plays a role in the time window of AIS. The WAKE-UP trial was one of the first studies to identify MRI patterns suggestive of a stroke in patient whose onset time was unknown.1,2 Over the past 10+ years, other studies have also attempted to identify the role of advanced neuroimaging guiding tPA administration for improved functional outcomes. The authors conducted a meta-analysis to test the hypothesis that tPA improves functional outcomes compared with placebo 4.5 - 9 hours after onset in AIS patients who received advanced neuroimaging. Before getting into the study, we need to better understand the terminology and different types of neuroimaging modalities available and how they play a role in strokes.
Medical Categories: Neurology
3 Likes
18 Dec 2019

December 18, 2019

Written by REBEL Cast, REBEL Core

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).
 
Medical Categories: Neurology
1 Like
3 Jun 2019

June 3, 2019

Written by REBEL Cast, REBEL CME

Background: Despite the lack of replication of the NINDS & ECASS-3 trials, guidelines recommend the use of tPA in the ≤4.5hr window after the onset of symptoms of acute ischemic stroke [2]. These recommendations used non-contrast computed tomography (NCHCT) for the selection of patients.  More recent endovascular studies have shown that perfusion-based imaging can show potential viable brain tissue beyond the 4.5 hour mark in patients with large vessel occlusions and result in good neurologic outcomes.  This advance has prompted investigators to look at perfusion-based technology to identify a larger cohort of patients without large vessel occlusion that may be candidates for systemic thrombolysis.  One of the big fears in stroke management is the concept of indication creep: finding more uses for a medication or product without strong evidence to support its use. The bigger question is, does this increase in use help the company’s bottom line or the patient? It is no wonder physicians are skeptical of industry sponsored trials, as we sometimes question the motives behind the study.  Now we have another industry sponsored trial: EXTEND. In this trial.

Medical Categories: Neurology
2 Likes
en English
zh-CN Chinese (Simplified)en Englishfr Frenchde Germanit Italianpt Portugueseru Russianes Spanishtr Turkish
0