American Heart Association

Monthly Archives: August 2014

Magnesium levels and Risk of Stroke in Women

Magnesium plays a role in several integral processes in the human body. Researches have sought to draw associations between magnesium levels and stroke in the past, most notably in the Atherosclerosis Risk in Communities (ARIC) study, concluding that low magnesium levels could be associated with the risk of ischemic stroke potentially through the effects of hypertension and diabetes. This Nurses’ Health Study (NHS) sought to further investigate this relationship by carrying out a nested case control study of ischemic stroke among 32,826 women who provided blood samples in 1989 and 1990. Strokes were confirmed according to the criteria of the National Survey of Stroke consisting mainly of sudden or rapid onset of neurologic deficits lasting more than twenty-four hours and, thereafter, incident ischemic strokes were matched 1:1 to controls who were free of stroke.

A total of 459 confirmed stroke cases and 459 controls had magnesium levels for analyses and this was divided into two main groups to differentiate between what can be considered “low” levels and normal levels as follows- (<0.82 mmol/l versus >0.82 mmol/l). Magnesium levels were measured by colorimetric assay on Hitachi 917 analyzer and tests of significance were conducted using Mantel-Haenszel and Fisher’s exact tests. With regards to the association between plasma magnesium and the risk of total ischemic stroke, the relative risk and 95% confidence interval for the lowest quintile compared to the highest quintile was 1.34 (0.86-2.10), p-trend 0.13. Women in the lowest quintile of plasma magnesium were most likely to be current smokers, use thiazide diuretics, post-menopausal hormone therapy, have hypertension and diabetes, and consume more alcohol  with median plasma magnesium levels in the lowest and highest quintiles being 0.78 mmol/l and 0.95 mmol/l respectively. Of note, the median magnesium levels (0.86 mmol/l) did not differ between ischemic stroke cases and controls.
 It was concluded that plasma magnesium levels were not associated with the risk of ischemic stroke in women across the full distribution of plasma magnesium, but that women in the lower quintile group had higher risk of ischemic stroke and this association remained unchanged after controlling for other factors associated with magnesium levels and stroke risk.

10 years of experience with telestroke in Germany

Ali Saad, MD

Müller-Barna P, Hubert GJ, Boy S, Bogdahn U, Wiedmann S, Heuschmann PU, and Audebert HJ. TeleStroke Units Serving as a Model of Care in Rural Areas: 10-Year Experience of the TeleMedical Project for Integrative Stroke Care. Stroke. 2014

This paper presents data from the German telestroke network, TEMPiS (TeleMedical Project for integrative Stroke Care). Established in 2003, it provides remote stroke expertise to rural areas in Germany. They used prospective registries from TEMPiS hospitals from 2003-12 and looked at typical stroke metrics.

Key findings were
– percentage of patients seen in the hospital with stroke/TIA as the diagnosis 19%->78%
– thrombolytic administration 2.6%->15.5%,
– median onset to treatment time 150min->120min
– door to needle time 80min->40min

Limitations of the TEMPiS experience include the lack of data on sustainability due to its novelty. The data excludes in-hospital strokes, but included hemorrhagic strokes. Included patients were from the largest insurer in the area, but it only covers 40% of the population.

This treatment model is great for rural areas without access to large stroke centers as well as patients who prefer treatment at their local hospital. It also provides evidence that although stroke centers provide excellent care, telestroke is a cost-effective solution to rural areas who may not have the local expertise needed. The TEMPiS experience echoes the success of the telestroke networks in GA, USA and Alberta, CA.

The authors highlight the need to develop relationships with the surrounding community hospitals and convince them that telestroke will provide care that is reliable and beneficial to their patients. This might seem to go without saying, but one must keep in mind that these rural hospitals have been managing without this service for years. It takes great leadership and some charisma to convince a group of doctors to change the way they’ve been practicing for years and invest in a new system.


Rajbeer Singh Sangha, MD

Mas JL, Arquizan C, Calvet D, Viguier A, Albucher JF, Piquet P, et al. Long-Term Follow-Up Study of Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis Trial. Stroke. 2014

The authors of this paper looked at comparing the long-term benefit–risk balance of carotid stenting versus endarterectomy for symptomatic carotid stenosis. In recent landmark trials, carotid stenting has been associated with a higher risk of procedural stroke or death compared to endarterectomy. It should be noted that this difference was mainly driven by mild and non-disabling strokes. The authors go on to point out that, it is crucial to know whether stenting is as effective as endarterectomy to prevent stroke recurrence in the long term. This study looked at long-term efficacy of the two treatments in terms of prevention of recurrent ipsilateral stroke beyond the procedural period and incidence of severe carotid restenosis or occlusion.

A total of 527 patients were enrolled from November 2000 to September 2005, at which time the safety committee recommended to stop enrollment for safety reasons. Outcomes (from January 2008 up to December 2012) were established retrospectively using complementary methods. During a median follow-up of 7.1 years (interquartile range, 5.1 to 8.8 years, maximum 12.4 years), the primary endpoint occurred in 30 patients in the stenting group compared to 18 patients in the endarterectomy group. The hazard ratio (HR) for stenting versus endarterectomy was 1.85 (95% CI 1.00–3.40; p=0.04). No difference was observed between treatment groups in the rates of ipsilateral stroke beyond the procedural period, severe carotid restenosis (>= 70%) or occlusion, death, myocardial infarction and revascularization procedures.

This article certainly confirms what has been seen in previous RCT’s, which is that the excess risk of stroke associated with stenting was driven by a significant increased risk of procedural non disabling strokes. Furthermore, no significant difference was noted in the occurrence of post-procedural ipsilateral strokes. Though the authors note that the long term differences between endarterectomy and stenting are only marginally different, they acknowledge that endarterectomy is clearly the favored option. This is based on the fact that procedural stroke risk is higher in stenting. An important question for the authors may be whether the early non-disabling strokes pose other long-term risks such as cognitive impairment or impaired quality of life. 

By |August 27th, 2014|treatment|Comments Off on LONG-TERM FOLLOW-UP STUDY OF EVA-3S

Time is Brain, again and again!

Chirantan Banerjee, MD

Muchada M, Rodriguez-Luna D, Pagola J, Flores A, Sanjuan E, Meler P, et al. Impact of Time to Treatment on Tissue-Type Plasminogen Activator–Induced Recanalization in Acute Ischemic Stroke. Stroke. 2014

The importance of time in hyperacute stroke care cannot be emphasized enough. In the NINDS tPA trial, the odds of a good functional outcome with IV tPA dropped from 2.6 if given between 0 – 90 min to 1.2 when given 271 – 360 min. Similarly, the NNT increased from 4.5 to 21.4. In the IMS-III trial, one of the major messages that emerged from the data was again that delays in time to angiographic reperfusion lead to a decreased likelihood of good clinical outcome in patients after moderate to severe stroke. With every step we take towards advancing acute stroke care, the importance of time to reperfusion keeps coming up again and again.

Now that the effect of time on functional outcome has been established, one interesting question that I have always had is that does delay in tPA delivery fail to improve outcomes with time because the brain tissue is not salvageable anymore, or that its efficacy to recanalize suffers as the clot matures, or a combination of the two. Muchada et al in the current issue of Stroke aimed to assess the influence of time on tPA induced recanalization in acute stroke patients. 508 consecutive acute stroke patients with proven MCA occlusions by TCD and who received IV tPA up to 4.5 hours, as well as ~6% who received tPA between 4.5 – 6 hours (selected by penumbral imaging) were included. Mean time to treatment was 171 min over the 7 year study period. TCD was repeated 1 hour post tPA. Any improvement in the TCD signal was considered to indicate recanalization. There was no linear association between time-to-treatment and recanalization. However, when converted to sequential 30 min time-to-treatment windows, as well as when dichotomized to <=270 min or >270 min, recanalization was seen to decrease with time. Several findings in the study corroborate with prior data. 

Overall recanalization rate of 36% is consistent with 30-40% previously reported. Also, higher NIHSS score, hyperglycemia, older age and female sex were again seen to decrease chance of recanalization.  Proximal MCA occlusions had a trend towards lower recanalization rate, especially after the first 90 min, in synergy with previous reports.  Distal occlusions had a recanalization rate ~30% regardless of time. The main limitation of the study is the measurement bias associated with use of TCD to assess vessel status. Also, the fact that only 6% patients received tPA >270 minutes affects the distribution of data. Some variables such as pre-treatment ASPECTS which have been previously shown to affect recanalization status were not included in the model.
This study again emphasizes the importance of time in acute stroke care, and finds poor recanalization outcomes beyond 270 min for proximal MCA occlusions. The authors argue that IV thrombolysis may be insufficient beyond this window, and more aggressive therapies should be explored. The critical question is, would it even matter if you do recanalize the occluded vessel at that point, or has the ship sunk already! 
By |August 26th, 2014|prognosis|Comments Off on Time is Brain, again and again!

Clinically Relevant IV-TPA Related Intracerebral Hemorrhage

Rizwan Kalani, MD
Rao NM, Levine SR, Gornbein JA, and Saver JL. Defining Clinically Relevant Cerebral Hemorrhage After Thrombolytic Therapy for Stroke: Analysis of the National Institute of Neurological Disorders and Stroke Tissue-Type Plasminogen Activator Trials. Stroke. 2014

When discussing the recommendation of administering intravenous tissue plasminogen activator (IV-tPA) in acute ischemic stroke, risks and benefits are conveyed to patients and/or families. If being given within 3 hours of symptom onset, at least some of us the NINDS IV-tPA study results with its ~6% symptomatic intracerebral hemorrhage (sICH) risk. It is important to realize, that although symptomatic or radiologically extensive, some intracerebral hemorrhage (ICH) may not contribute to outcome.

Rao et al evaluated which of 4 different ICH definitions best determined clinically relevant ICH, defined as altering long term disability by modified Rankin Scale (mRS) at 3 months, as well as mortality at 3 months post-stroke from the NINDS tPA trial public data set. Only cases of ICH within 36 hours post IV-tPA were included. The definitions studied were: parenchymal hematoma (PH), and the sICH definitions of: the NINDS tPA study, ECASS 2 study, and a modified version of the Safe Implementation of Thrombolysis in Stroke Monitoring Study (mSITS-MOST). The PH definition is a pure radiologic one whereas the other three are mixed clinical and radiologic. For each definition, the authors compared the actual mRS outcomes of those who received IV-tPA and the projected 3 months outcomes of those who didn’t get tPA (based on a logistic regression model taking into account 17 variables including age, pre-existing disability, several objective markers on presentation, vascular risk factors, radiologic features, stroke location and etiology). The difference between the observed mRS with tPA and predicted mRS without tPA was compared.

Of the 312 patients treated with IV-tPA, 10.6% had any ICH by radiologic assessment. 5.4% had PH, 6.4% NINDS defined sICH, 3.8% ECASS 2 defined sICH, and 1.9% mSITS-MOST defined sICH. The ECASS 2 and mSITS-MOST definitions had the largest (and statistically significant) mRS differential between actual and predicted 3 month mRS (ECASS 2 – 1.94 mRS, mSITS-MOST – 2.18) as well as mortality analysis (ECASS 2 – 57.1%, mSITS-MOST – 48.9%).

Thus, patients meeting these definitions had the greatest and significant differences in their actual 3 month outcomes compared to what would be expected without tPA. The ECASS 2 definition identified twice as many patients as having clinically relevant sICH compared to the mSITS-MOST definition.

This report supports the idea that the NINDS study sICH definition includes patients with ICH that does not actually affect 3 month clinical outcomes. This study is the second demonstrating the ECASS 2 definition (any ICH with a decrease in NIHSS 4) may have more utility. Using this, for patients receiving IV-tPA based on the NINDS study inclusion/exclusion criteria, a clinically relevant ICH would occur in 3.8% and ICH resulting in death would in 2.5%.

I think it would be important to discuss clinically important ICH rate (not just overall sICH rate) during risk/benefit conversations with patients for IV-tPA with acute ischemic stroke. A standard definition is also going to be crucial in future, novel therapeutic clinical trials.

By |August 25th, 2014|diagnosis and imaging|Comments Off on Clinically Relevant IV-TPA Related Intracerebral Hemorrhage

Acute Stroke Neuroimaging, Endovascular Reperfusion Therapy and Outcome

Mark N. Rubin, MD

Lum C, Ahmed ME, Patro S, Thornhill R, Hogan M, Iancu D, et al. Computed Tomgraphic Angiography and Cerebral Blood Volume Can Predict Final Infarct Volume and Outcome After Recanalization. Stroke. 2014

As was recently discussed, acute stroke evaluations start out fairly structured but can quickly get complicated. This is especially true if a provider is considering endovascular reperfusion therapies, which currently exist in a sort of evidence-based-therapeutic purgatory. We have amazing “physiology” neuroimaging studies, namely perfusion-based CT and MRI, that make all the sense in the world to be helpful in selecting for patients at risk but treatable and those for whom the proverbial ship has sailed, but, to oversimplify, no dice.

While experts work on better trial design with better devices and better imaging modalities, we have to take care of these patients now.

That being the case, the Ottawa Stroke Research Group has made an interesting contribution to the field of advanced neuroimaging for acute stroke decision making. They put together a cohort of prospectively enrolled patients with acute ischemic stroke and “a clean CT” who ended up triaged to the endovascular suite for intervention. The group routinely screens for large vessel occlusion and perfusion abnormalities prior to endovascular treatment, and thus embarked on a study to compare a non-contrast CT to CTA source images to CT-perfusion based cerebral blood volume (CBV) findings to 24-hour infarct on a repeat CT head and 30-day outcome. The details are interesting, but overall, the CTA source images and CBV were better able to predict size of infarct on CT at 24h, which was fairly well tied to 30-day outcome in their cohort.

To suggest we should start routinely triaging patients to the endovascular suite based on their methodology and findings alone would be a perilous jump in logic. However, at least in this particular subset of patients, these findings can inform future trials and at least gives us a sense that, while still in the Wild West of complex acute stroke care, these fairly readily available and rapidly obtained radiographic signs may be of some clinical utility.

By |August 22nd, 2014|diagnosis and imaging|Comments Off on Acute Stroke Neuroimaging, Endovascular Reperfusion Therapy and Outcome

Does an increase in parent vessel diameter predict the occurrence of a stroke in that territory?

Prachi Mehndiratta, MD

Shoamanesh A, Masoud H, Furey K, Duerfeldt K, Lau H, Romero JR, et al. Larger A1/M1 Diameter Ratio Predicts Embolic Anterior Cerebral Artery Territorial Stroke. Stroke. 2014

This study attempts to answer this question by retrospectively studying the anatomic characteristics of the parent vessel in patients with anterior cerebal artery (ACA) and middle cerebral artery (MCA) ischemic stroke. Twenty seven cases of ACA stroke admitted between 2008 and 2012 were contrasted with twenty eight controls that comprised of MCA territory infarcts. Measurements were rated on a CT angiogram or time of flight MR angiogram if a CT angiogram was not available. Diameters of the proximal ACA and MCA arteries (A1 and M1 respectively) and an A1/M1 diameter ratio was captured by two raters independently. A third rater assessed the branching angle between the Internal carotid artery (ICA) and the ACA and MCA.

The authors found that those with ACA stroke had a greater prevalence of Diabetes Mellitus and were less likely to suffer from atrial fibrillation. Proximal ACA or A1 diameter was larger than proximal MCA diameter (mean: 2.5 vs. 2.1 mm, p=0.003) in patients with ACA stroke and intuitively the A1 to M1 diameter ratio was also higher. ICA-MCA and ICA-ACA bifurcation angles did not differ between cases and controls. When multivariate analysis was performed A1/M1 diameter ratio (C-statistic: 0.81, 95% CI 0.70 – 0.93, p<0.001) was found to be a stronger predictor of embolic ACA stroke than A1 diameter alone (C-statistic: 0.71, 95% CI 0.57 – 0.84, p=0.009). Forty one percent of patients with ACA stroke were found to have contralateral A1 segment hypo/aplasia.

These are interesting findings however as the authors acknowledge, the generalization of the results should be viewed with caution. The number of cases is small; the raters are presumably blinded although not clearly identified as such and majority of the rating is performed on time of flight MR angiograms which are susceptible to a great degree of artifact.  It is unclear what the etiology of stroke is in the 27 ACA stroke cases and if there were any  atherosclerotic changes in the parent vessels that might have contributed to change in flow dynamics and consequently a change in the diameter of the vessel. The results are intriguing and  hypothesis generating but I would wait for a more rigorous study with both anatomic and physiologic data to put my trust in vessel diameter measurements.
By |August 21st, 2014|diagnosis and imaging|Comments Off on Does an increase in parent vessel diameter predict the occurrence of a stroke in that territory?

Once Upon a Time in Mexico: debunking of the Hispanic Paradox

Vikas Pandey, MD

The idea of the Hispanic paradox (not to be confused with the Obesity Paradox, Obstructive Sleep Apnea paradox, Statin Paradox, or stroke survivor Kevin Sorbo’s 2010 movie “Paradox”) is the epidemiological mystery that while Hispanic Americans generally have lower socioeconomic status and education level, higher vascular risk factors and less access to healthcare, their mortality risk due to medical illnesses has been found to be equivalent to, or better than (in the case of ischemic stroke) the non-Hispanic white (NHW) population. While there has been much controversy to the reasons for this difference and as to whether a difference even exists, ascertainment of any differences present has value given the potential for providing population-specific stroke prevention and treatment measures.

The published study delved into the difference between Hispanic American (specifically Mexican Americans (MA), 63% of the Hispanic population in the U.S.) and NHW population stroke risk and how the difference has changed over time, specifically from 2000 to 2011. The group in 2006 had previously reported a 42% lower 28-day ischemic stroke case fatality rate and 21% lower all-cause mortality rate following ischemic stroke in MAs compared to NHWs. For this study, they used a population that was part of the Brain Attack Surveillance in Corpus Christi (BASIC) project that takes place in Nueces County, Texas with the majority of residents living in the city of Corpus Christi. The population mainly consisted of stable, non-immigrant persons with very few undocumented residents, making reasons to return to Mexico after stroke unlikely. The group used two-sample statistics to calculate differences in both 30-day mortality and 1 year mortality after an ischemic stroke event. The publishing group adjusted for sex, differences in age quartile distribution, diabetes, coronary artery disease, high cholesterol, history of stroke/TIA, atrial fibrillation, hypertension, smoking status, insurance status, and stroke severity based on NIHSS and found MAs had younger age, more diabetes and hypertension while NHWs had higher prevalence of atrial fibrillation and smoking and were more likely to be insured. The group recorded 4,413 ischemic stroke cases of which 44.7% were in NHW and 55.2% in MA. Across the 11-year time period, the 30 day mortality in NHW decreased from 7.6% to 5.6% (p=0.24) and 1 year mortality from 20.8% to 15.5% (p=0.02). MA mortality rate across same time period stayed the same (5.1% to 5.2%) and slight decline in 1 year mortality rate (17.4% to 15.3%, p=0.26). The ethnic differences between the groups were clear in 2000 (30 day: p=0.01, 1 year: p= 0.06), however by 2011 the differences had diminished (30 day: p=0.63, 1 year: p=0.92).

The authors were able to demonstrate that post-stroke survival advantage of MAs compared to NHWs had diminished over the time frame, but what reasons for this change could there be? The ischemic stroke mortality for all race/ethnic groups has been declining however it appears from the data that this decline is not as pronounced in MAs and other ethnic groups have “caught up”. The other possibility is that there was never any difference to begin with and improvement in record collecting may account for this return to equivalency. The classic explanations for why the Hispanic paradox exists include, for one, that Hispanics tend to have more strokes related to small vessel disease which can be partially explained given the finding in the current group’s data of increased incidence of hypertension and diabetes in MAs. These strokes tend to be smaller and less likely to cause mortality whereas the NHW population with the statistically higher chance of atrial fibrillation may lead to more devastating ICA and MCA occlusions. Proponents of a genetic difference between MA and Mexicans in Mexico would be quick to point out that those Mexicans that are in the U.S. may be more innately capable of withstanding disability from ischemic strokes given that they were able to immigrate into the country and find work to be able to sustain a living. There is also the concept of “Salmon bias” named after the fish which after living out in the sea, return to the river where they were born to spawn and die, applying in this scenario because of the subset of the MA population which may return to Mexico after suffering an ischemic event thus becoming statistically immortal. The authors did an excellent job of making sure that none of these factors were biasing their data by recording no difference in NIHSS severity, and picking a stable population with very little immigration or emigration. They have shown that there may be in fact no difference between the ethnic groups and, on the contrary, the MA population’s mortality rate due to ischemic stroke is not decreasing as much as it should making primary and secondary stroke prevention measures in this subset a point of special emphasis.  

Posted by  Vikas Pandey (@DrVikasNeuro)

By |August 20th, 2014|epidemiology and genetics|Comments Off on Once Upon a Time in Mexico: debunking of the Hispanic Paradox

Characteristics of Intracerebral Hemorrhage in Rivaroxaban vs. Warfarin

Abdel Salam Kaleel, MD, MSc

Hagii J, Tomita H, Metoki N, Saito S, Shiroto H, Hitomi H, et al. Characteristics of Intracerebral Hemorrhage During Rivaroxaban Treatment: Comparison With Those During Warfarin. Stroke. 2014

This study compared the clinical characteristics, neuroradiologic findings, and functional outcomes of patients taking rivaroxaban and patients taking warfarin for nonvalvular atrial fibrillation who subsequently developed intracerebral hemorrhages. In particular, it sought to determine which group had more favorable characteristics after ICH. This study was conducted between April 2011 and October 2013 in the Hirosaki Stroke and Rehabilitation Center and included 585 ICH patients, 5 of whom had ICH while taking rivaroxaban, 56 of whom had ICH while taking warfarin, and 524 of whom had ICH on no anticoagulant therapy. ICH was diagnosed by immediate computed tomography (CT) with a follow up scan at day 2
after admission. The hematoma volume, expansion of hematoma, and extent of cerebral microbleeds were determined in surviving patients; Vitamin K was given for reversal of anticoagulation in patients on warfarin, but no reversal was given for patients previously on rivaroxaban. Scales and scores, namely CHADS2, HAS-BLED, and modified Rankin Scales, were determined on each patient. The differences were then computed by Mann-Whitney U test or Fisher’s exact test. 

Interestingly, patients on rivaroxaban had a smaller hematoma volume while none of them had expansion of hematoma or underwent surgical treatment. Those patients who had been taking warfarin on admission experienced expansion of hematoma in 21% and required surgical treatment in 11%. These findings occurred in the setting of rivaroxaban-treated patients having more cerebral microbleeds than the warfarin-treated group. When comparing the patients with mRS of 0 and 1 before admission, none of the patients in the rivaroxaban group had mRS >4 at discharge, but half of the patients taking warfarin did. Additionally, ten of the warfarin-treated patients died whereas none of the rivaroxaban-treated patients did. While the study did have several limitations, including single-center retrospective analysis and small number of study patients, it did provide valuable comparisons and some insight in characteristics of patients who suffered from ICH while taking warfarin or rivaroxaban.
By |August 20th, 2014|hemorrhage|Comments Off on Characteristics of Intracerebral Hemorrhage in Rivaroxaban vs. Warfarin

Using IV-tPA Without Vessel Occlusion – now evidence-based

Ali Saad, MD

Lahoti S, Gokhale S, Caplan L, Michel P, Samson Y, Rosso C, et al. Thrombolysis in Ischemic Stroke Without Arterial Occlusion at Presentation. Stroke. 2014

It is difficult to justify vessel imaging as a requirement prior to the administration of tPA. Firstly, the majority of strokes do not demonstrate large vessel occlusions because they are due to small-vessels or a large vessels that have recanalized. Secondly, it would create a delay in treatment. The major clinical trials proving the efficacy of IV-tPA did not require such imaging.

It has remained common practice, although not evidence-based, to make a clinical diagnosis of ischemic stroke with a corroborating history, especially in centers without acute MRI capability. Several studies have also demonstrated tPA is safe in the case of stroke mimics, assuming there is no absolute contraindication.

This paper provides evidence that our common practice significantly improves patient outcomes without placing them at high risk. 103 patients who received IV t-PA and 153 who didn’t from several centers were retrospectively compared for 3 month mRS and symptomatic ICH (sICH). Patients also had to have follow-up MRI within 48 hours to exclude stroke mimics from the analysis (a great strength of this study) and follow up CTA or MRA to exclude large vessel occlusion.

Thrombolyzed patients did better than non-thrombolyzed patients when measured by 3 month mRS of 0 (perfect), 0-1 (excellent), or 1-2 (good). Even patients with a resultant mRS of 0 had an adjusted OR of 5.81 (p<0.01). Symptomatic ICH was more common in the thrombolysis group 4.9% vs 0.7% (p=0.04). Number needed to treat for an mRS 0-1 was 5.7 at the cost of 1 in 24 sICH without an increase in poor outcome (mRS 4-6). The adjusted OR for poor outcome, 0.65, was not significant (95% CI 0.31-1.40, p=0.27).

In subgroup analysis, patients were divided into lacunar and non-lacunar strokes. Both groups who received tPA reached statistical significance for mRS 0, but only the non-lacunar group had significantly better outcomes at mRS 0-1 or 1-2. Neither group had significantly worse poor outcomes. Patients who got tPA in both groups had more sICH, 6.1% (5 patients) in the nonlacunar and 3.7% (2 patients) in the lacunar.

“Perfect outcome”, as the authors call it, with an mRS of 0 is an interesting term that I hope becomes common terminology in future articles as the treatment options for acute ischemic stroke continue to improve.

The 2 groups were poorly matched due to small cohort size, namely number of patients, DM, HTN, age, NIHSS. Despite the tPA group being older, having more vascular risk factors, and a higher NIHSS on presentation they still had better outcomes than the no tPA group

Limitations of this study:
– not randomized, so patients who didn’t receive tPA aren’t necessarily comparable to those who did. This introduces treatment bias and the possibility of undocumented exclusion criteria
– retrospective data

How this paper changes my practice:
– citing evidence that giving tPA for patients even in the absence of a vessel occlusion is more likely to help outcome with minimal risk

By |August 19th, 2014|treatment|Comments Off on Using IV-tPA Without Vessel Occlusion – now evidence-based