gkaur

Gurmeen Kaur, MBBS
@kaurgurmeen

Shah S, Xian Y, Sheng S, Zachrison KS, Saver JL, Sheth KN, et al. Use, Temporal Trends, and Outcomes of Endovascular Therapy after Interhospital Transfer in the United States. Circulation. 2019

The current decade has seen a revolution in stroke care with the advent of endovascular therapy (EVT) and extended timelines for stroke intervention. With the expansion of stroke care, there is a tremendous increase in the need for angiographic suites and providers. Most smaller, non thrombectomy capable centers have set up contracts with academic or bigger centers nearby to transfer their stroke patients for emergent large vessel occlusions.

However, given that the number of treatable strokes far exceeds the number of thrombectomy capable centers, it is the right time to review our nationwide policies on transfers for improved patient care and quality improvement. In this paper, authors Shah et al. have done a great job elucidating the temporal trends in transfer of patients for EVT and how those transfer trends are influencing the final outcome, using the Get with the Guidelines database.

Gurmeen Kaur, MBBS
@kaurgurmeen

Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, et al. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. NEJM. 2018

Recently, the impressive results of the MRI-Guided Thrombolysis trial, popularly known as WAKE UP, were announced at the European Stroke Organization Conference 2018.

In an investigator initiated, multicenter, randomized, double blind, placebo controlled clinical trial, patients waking up with stroke or those with undetermined last known well because of aphasia and confusion were included between 18-80 years of age.

All patients included did not have contraindications to getting IV tPA, but did not qualify because of the unclear LKW. Previous studies have determined that at the 4.5-hour mark, roughly estimating, the DWI shows positivity but the FLAIR does not show parenchymal involvement. Hence, the mismatch between DWI and FLAIR was used to screen and select patients to be divided into 2 groups: one that received alteplase and the other group that received placebo. Interestingly, patients that qualified for mechanical thrombectomy were excluded from this trial.

Gurmeen Kaur, MBBS
@kaurgurmeen

Savitz SI, Baron J, Yenari MA, Sanossian N, Fisher M. Reconsidering Neuroprotection in the Reperfusion Era. Stroke. 2017

The past few years have seen radical changes in stroke care, development of mechanical thrombectomy as standard of care and, more recently, extension of the time limit to 24 hours in the setting of the DAWN trial. With these changes, exploration of neuroprotective agents is the need of the hour, with an aim to extend the potential window for thrombolytic therapy.

Neuroprotection trials, unfortunately, have a dismal history. Reasons attributed to that may be wrong timing or monotherapy trials. Additionally, designing these trials has been difficult because of difficulty with designing animal models that exactly replicate the stroke penumbra.

Gurmeen Kaur, MBBS
@kaurgurmeen

Froehler MT, Saver JL, Zaidat OO, Jahan R, Aziz-Sultan MA, Klucznick RP, et al. Interhospital Transfer Prior to Thrombectomy is Associated with Delayed Treatment and Worse Outcome in the STRATIS Registry. Circulation. 2017

Since “Time is Brain” when it comes to ischemic strokes and large vessel occlusions (LVO), the authors designed the STRATIS trial, which is a multicenter, observational, single-world perspective on real-life issues faced during transfers of patients for tPA and mechanical thrombectomy.

1000 patients with anterior circulation LVOs were included over a 22-month period. About half of the patients were transferred to a comprehensive stroke center which is capable of mechanical thrombectomy, and the remaining half was transferred from an outside hospital to an endovascular-capable center. IV-tPA was administered to 628 patients; 329/539 (61.0%) of direct patients and 299/445 (67.2%) of transferred patients (p=0.044).