June 21, 2021

Background: Acute basilary artery occlusion has a high morbidity and mortality.  Treatment strategies for acute basilar artery occlusion are rather sparse.  Endovascular research over the last 5 years (REBEL EM Post) adds little to the conversation of these strokes as very few patients with basilar artery strokes were included. The Basilar Artery International Cooperation Study (BASICS) was a prospective observational registry in which ≈600 patients were divided into three groups: antithrombic treatment only (antiplatelet drugs or systemic anticoagulation), primary intravenous thrombolysis (including subsequent intra-arterial thrombolysis), or intra-arterial therapy (which compromised thrombolysis, mechanical thrombectomy, stenting, or a combination of these approaches) [2].  The majority of patients (68%) received intra-arterial therapy, but the study showed no statistically significant superiority for any treatment strategy.  In a subgroup analysis of the BASICS registry, patients with the most severe neurologic deficits (NIHSS >19) showed a trend toward lower risk of a poor neurologic outcome with endovascular therapy. Clearly, additional data is needed to elucidate the role of endovascular treatment in basilar artery strokes.

March 18, 2021

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 (see CVA Workflow 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).  In 2020, we reviewed an article by Yang and colleagues that demonstrated non-inferiority to an endovascular intervention only approach (with a 20% non-inferiority lower limit) (REBEL EM). Recently, two more studies have been published on this topic.

September 3, 2020

Background: The risk of a subsequent ischemic stroke in the first few months after an acute ischemic stroke or transient ischemic attack is approximately 5 to 10%. In these patients Aspirin has been used to prevent secondary ischemia, and trials have shown a reduced risk thereof when the P2Y12 receptor blocking antiplatelet agent Clopidogrel is added. Clopidogrel, however, requires hepatic conversion to its active form through a pathway that is inefficient in 25% of white and 60% of Asian patients and efficacy is uncertain in these patients. Not dependent on metabolic activation is the direct-acting ticagrelor with similar P2Y12 receptor blocking effect. While a trial of ticagrelor alone did not show benefit over aspirin; in their sub-group analysis of patients who had received aspirin within 7 days before randomization, treatment with ticagrelor may have reduced the risk of major vascular events. This finding suggested that the effect of aspirin received before entry into the trial might have persisted for several days after treatment and that the combination of ticagrelor and aspirin may prevent subsequent strokes.

May 14, 2020

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.

March 23, 2020

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:

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