Yet for all the chest thumping congratulations of themselves they still do not check the proper primary outcome. It is NOT recanalization, it is 100% RECOVERY YOU FUCKING IDIOTS. tPA DOES not WORK, it fails at full recovery 88% of the time.
Your definition of success is totally wrong, step up to the plate and deliver actual results.
For Your Patients-Acute Ischemic Stroke: The Clinical Characteristics that Could Help in Triaging Patients for tPA or Thrombectomy
Neurology Today:
October 18, 2018 - Volume 18 - Issue 20 -
p 15
doi: 10.1097/01.NT.0000547502.43783.4a
For Your Patients
ARTICLE IN BRIEF
Researchers
elucidated the clinical, imaging, and thrombus characteristics that
could potentially help in triaging patients in the field to either
receiving intravenous tissue plasminogen activator (tPA) or transport to
a thrombectomy center.
A more distal thrombus location, greater thrombus
permeability, and longer time to recanalization assessment appear to be
associated with successful recanalization following intravenous
alteplase in patients with acute ischemic stroke, according to a
September 11 report in the Journal of the American Medical Association.
The study elucidates clinical, imaging, and thrombus
characteristics that could potentially help in triaging patients in the
field to either receiving intravenous tissue plasminogen activator (tPA)
or transport to a thrombectomy center.
“Our study provides some extra color in terms of
decision-making around whether patients should receive tPA or
thrombectomy,” said corresponding author Andrew M. Demchuk, MD,
professor of neurology at the University of Calgary in Alberta, Canada.
“If the clot is remote and has porosity, tPA is very likely to work in
that situation. That's a patient who doesn't need to bother with a long
transport to a thrombectomy center, because tPA will likely open the
clot. In other situations where the carotid artery is involved, tPA has a
very low likelihood of success,” Dr. Demchuk said.
STUDY DETAILS, FINDINGS
The INTERRSeCT (Identifying New Approaches to
Optimize Thrombus Characterization for Predicting Early Recanalization
and Reperfusion With IV Alteplase and Other Treatments Using Serial CT
Angiography) study is a multicenter prospective cohort study at 12
centers in Canada, South Korea, Spain, the Czech Republic, and Turkey.
First enrollment was in March 2010 and final follow-up occurred in March
2016.
Dr. Demchuk and colleagues examined demographics,
clinical characteristics, time from alteplase to recanalization, and
intracranial thrombus characteristics for 575 patients with acute
ischemic stroke and intracranial arterial occlusion demonstrated on
computed tomographic angiography (CTA).
All patients underwent a head and neck CTA at
baseline and repeat head CTA four hours later. The researchers assessed
the extent of intracranial thrombus using the clot burden score (a score
of 0 implies complete occlusion of the ipsilateral anterior circulation
vessels; a score of 10 implies no occlusion). Permeability of
intracranial thrombus was assessed using the residual flow grade.
The primary outcome was successful recanalization
defined as a revised arterial occlusion scale score of 2b or 3 on repeat
CTA or conventional cerebral angiogram obtained within six hours of
initial CTA.
Of the 575 patients in the cohort, 275 patients (47.8
percent) received intravenous alteplase only, 195 (33.9 percent)
received intravenous alteplase plus endovascular thrombectomy, 48 (8.3
percent) received endovascular thrombectomy alone, and 57 (9.9 percent)
received conservative treatment.
Successful recanalization occurred in 157 patients
(27.3 percent) overall, including in 143 (30.4 percent) of those who
received intravenous alteplase and 14 (13.3 percent) who did not.
Dr. Demchuk noted that the findings suggest
recanalization with intravenous alteplase is a continuous process over
time. “tPA has a short half-life, but one of the surprising findings is
that we saw recanalization even at later points after tPA has supposedly
become inactive,” he said. “We believe the clot is softened by the tPA
and starting to break up, but the process continues with natural lysis
over many hours.”
Also intriguing is the finding that recanalization is
associated with increased porosity, suggesting that with highly
permeable clots the tPA has more surface area to work on, Dr. Demchuk
said.
More generally, he said the success rate of tPA should be encouraging to clinicians. “tPA works,” he told Neurology Today.
“We do have a cohort in this study for whom it is contraindicated. But
the between-group recanalization rates are quite remarkable. Clinicians
are sometimes hesitant to use tPA because it does have risks, but I
believe these results should provide some comfort.”
Finally, Dr. Demchuk said he hopes information from
the study can inform clinical trials of other agents, or adjuncts to
tPA, that can lead to improvements in clinical outcome for patients with
stroke.
EXPERT COMMENTARY
Experts who reviewed the report for Neurology Today
agreed the study is a strong one that provides important information
about which patients should and should not be considered for tPA.
“This international multicenter study is very
important because it investigated how intravenous alteplase treatment
and thrombus characteristics are associated with clinical outcomes in
patients with acute ischemic stroke,” said Bart M. Demaerschalk, MD,
MSc, professor of neurology at Mayo Clinic in Phoenix, AZ.
“This study is helpful in designing the EMS transport
plans for regional stroke systems of care and in deciding whether to
transport patients with acute ischemic stroke to a thrombectomy-capable
stroke center or comprehensive stroke center for endovascular therapy.”
Dr. Demaerschalk added: “In the event that transport
times from the field are a few hours longer to a comprehensive stroke
center compared with an acute stroke-ready hospital or a primary stroke
center, evaluation at a telemedicine-enabled acute stroke hospital, for
instance, or at a primary stroke center for initial treatment with
intravenous alteplase is likely the better option based on reasonable
recanalization rates with alteplase over several hours.”
“The study also points to a clear need to predict
with clinical and imaging criteria which patients are most suitable for
transfer to stroke centers capable of endovascular therapy versus who
can remain at a local community stroke center,” he said.
Tudor G. Jovin, MD, professor of neurology at the
University of Pittsburgh, agreed. “This topic has become more important
with the advent of thrombectomy because it has implications with regard
to which patients should be routed directly to an endovascular center
and which should go first to a closer primary care center to receive
tPA,” Dr. Jovin said. “One of the biggest issues in stroke care today is
how to build a system of care that can appropriately triage patients.”
Dr. Jovin, who is also director of the University of
Pittsburgh Medical Center Stroke Institute and the UPMC Center for
Neuroendovascular Therapy, said: “The authors of the study are to be
congratulated for a strong study. One of the limitations is that the
decision regarding the most appropriate delivery site should ideally be
made in the pre-hospital setting. With the advent of mobile stroke units
in ambulances, the kind of information the study provides would be very
useful. But whether mobile stroke units will be standard and widely
used remains to be seen.”
Another approach would be to determine if certain
clinical measures that can be ascertained in the ambulance can be
correlated with successful recanalization with either tPA or
thrombectomy. Dr. Jovin said he is among investigators leading a
randomized trial to look at that question in Catalonia, Spain, using the
Rapid Arterial Occlusion Evaluation Scale.
LINK UP FOR MORE INFORMATION:
•. Menon BK, Al-Ajilan FS, Najm M, et al Association
of clinical, imaging, and thrombus characteristics with recanalization
of visible intracranial occlusion in patients with acute ischemic stroke
https://jamanetwork.com/journals/jama/fullarticle/2702146. JAMA 2018; 320(10): 1017–1026.
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