Monthly Archives: October 2020

Manya Khrlobyan, DO, MS

Flint AC, Avins AL, Eaton A, Uong S, Cullen SP, Hsu DP, Edwards NJ, Reddy PA, Klingman JG, Rao VA, et al. Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment. Stroke. 2020;51:2697–2704.

Among patients presenting with a large vessel occlusion (LVO), the standard of care is administering IV tPA prior to endovascular therapy, but this practice has recently come under question. With the recanalization rate of large vessel occlusion in acute ischemic stroke being less than 20% with IV tPA alone, many are questioning if proceeding straight to endovascular intervention makes more sense. One of the arguments against administering IV tPA is the risk of distal embolization rendering a once accessible clot inaccessible for mechanical thrombectomy.

This study retrospectively collected data from a large integrated stroke telemedicine program to examine the impact of IV tPA administration prior to endovascular therapy (EVT) on the rate of distal embolization and rate of target recanalization, and it assessed both the short- and long-term clinical outcomes using NIHSS and mRS, respectively.

Saurav Das, MD
@sauravmed

Cummings C, Almallouhi E, Al Kasab S, Spiotta AM, Holmstedt CA. Blacks Are Less Likely to Present With Strokes During the COVID-19 Pandemic: Observations From the Buckle of the Stroke Belt. Stroke. 2020.

During our monthly institutional journal club, we recently discussed a provocative health affairs blog post on systemic racism and the need for new standards for publishing on racial health inequities.¹ The blog made a strong case regarding how biological factors and physician mistrust have been inaccurately named as an explanation for racial disparities in health outcomes without pronouncing the root cause as “systemic racism.” Subsequently, I read this brief report by Cummings et al. published in Stroke about racial disparities in telestroke consults in a large registry maintained at the Medical University of South Carolina during the COVID-19 pandemic. In this post, I will discuss the findings of the authors and reflect in light of the aforementioned blog.

The authors performed a retrospective chart review of 5852 patients in their telestroke registry comprising a network of 27 centers during the period of March 2019 to April 2020. The patients were grouped by months in which consult occurred, as well as into two groups: before and after the pandemic (March 1, 2020). The weekly census of patients presenting with stroke was significantly lower during the COVID-19 epoch (77 [interquartile range, IQR 69-84] vs 112 [IQR 102-120], p=0.002). There was a lower percentage of Black patients presenting during the pandemic (13.9% vs 29% before, p<0.001). Interestingly, a higher percentage of patients that presented received intravenous tissue Plasminogen Activator (tPA) during the pandemic (15.5% before vs 12.5% during the pandemic, P= 0.037), but the number of mechanical thrombectomies (MT) per week was lower during the pandemic (1 [IQR, 0.5-1] vs 3 [IQR, 1-4], P=0.022). This increased rate of tPA administered during the pandemic was seen in the Black patients as well (22.4% during the pandemic vs 13.5% before the pandemic, P=0.022). There were no differences in median age, sex, time from symptom onset to presentation, baseline NIHSS, rate of transfer to a MT capable center and rate of MT between Black patients presenting before and after the pandemic.