Deans' stroke musings: Higher Standard for 'Success' Better In Stroke Reperfusion?

Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Thursday, April 26, 2018

Higher Standard for 'Success' Better In Stroke Reperfusion?

Still doing absolutely nothing to address the 5 causes of the neuronal cascade of death.
Until that starts occurring better outcomes will not happen.
https://www.medpagetoday.com/cardiology/pci/72222?xid=nl_mpt_DHE_2018-04-10&eun=g424561d0r&pos=0&utm_source=Sailthru&utm_medium=email&

mTICI 2B may not make the cut for functional outcomes, study finds

by Nicole Lou,

Reporter, MedPage Today/CRTonline.org April 09, 2018

Successful reperfusion is better defined as Modified Thrombolysis in Cerebral Infarction (mTICI) 2C and 3 at the end of thrombectomy, a group of French researchers argued.

Stroke survivors were equally likely to have a favorable outcome -- a modified Rankin Scale (mRS) score 0 to 2 at 90 days -- whether they were left with mTICI 2B-, 2C-, or 3-grade reperfusion at the end of the procedure (42.9% versus 56.7% versus 56.7%, P>0.05).

However, grades 2C and 3 together held an advantage over the 2B group (OR 1.72, 95% CI 1.01-2.90). This difference persisted after adjustment, Cyril Dargazanli, MD, MSc, of Hôpital Gui de Chauliac in Montpellier, France, and colleagues reported online in Stroke

"Combining mTICI 2C and TICI 3 grades helps to determine a subgroup of patients who achieve better functional outcomes than mTICI 2B patients," the investigators concluded. "Achieving mTICI 2C/3 reperfusion should be the new aim of mechanical thrombectomy for anterior circulation large vessel occlusion."

Gregory Albers, MD, of California's Stanford University Medical Center, commented to MedPage Today that he agreed with this, having also observed in the DEFUSE 3 trial better outcomes the closer to perfect that reperfusion gets.

Logistically speaking, it's not that big a change for operators or clinical trialists to redefine successful reperfusion as mTICI 2C and 3, he said. "However, it is not always possible to achieve at 2C-3 and it is very important not to do additional interventions that place the patient at risk for complications," he cautioned.

Patients included in the study were enrolled in the randomized Contact Aspiration Versus Stent Retriever for Successful Revascularization (ASTER) trial designed to compare the mechanical thrombectomy strategies of contact aspiration and stent retriever therapy across eight high-volume stroke centers in France.

Of the 381 trial participants -- all presenting with suspected ischemic stroke secondary to occlusion of the anterior circulation within 6 hours of onset of symptoms -- 290 were included in the analysis because they had mTICI 2B (30.7%), mTICI 2C (21.4%), or mTICI 3 (47.9%) reperfusion.

Use of IV thrombolysis treatment was allowed in ASTER. An external core laboratory provided angiographic outcome adjudication.

The overall distribution of mRS scores did not not significantly favor the higher mTICI grades, Dargazanli's group reported.

Nonetheless, neurological improvement (defined as an NIH Stroke Scale score of 0 to 1) at 24 hours was significantly more likely for the mTICI 2C and 3 groups than 2B (65.5% and 60.2% versus 39.8%, adjusted OR 2.27, 95% CI 1.26-4.08). Moreover, these patients showed a bigger improvement in NIH Stroke Scale at 24 hours (8.4 and 7.0 versus 3.5 points, adjusted OR 3.4, 95% CI 1.4-5.4).

Of note, the near-complete reperfusion achieved when mTICI 2C and 3 were reached was associated with lower 90-day all-cause mortality (8.3% and 14.2% versus 23.8% for mTICI 2B, adjusted OR 0.37, 95% CI 0.16-0.83) -- although this lost statistical significance upon further adjustment for procedure-related adverse events and parenchymal hematoma (adjusted OR 0.53, 95% CI 0.22-1.26).

There was no interaction between mTICI 2B-3 reperfusion and onset-to-reperfusion time on favorable outcome, overall mRS distribution, early neurological improvement, 24-hour change in NIH Stroke Scale, and mortality.

One limitation of their approach, the authors acknowledged, is that mTICI 2C reperfusion "may be difficult to interpret given the lack of objective parameters such as obvious arterial occlusion."

The study was sponsored by the Fondation Ophtalmologique Adolphe de Rothschild. The ASTER trial was supported by a grant from Penumbra.

Dargazanli disclosed no relevant conflicts of interest.