Deans' stroke musings: Article Commentary: “Advances in Acute Ischemic Stroke Therapy”

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.

Wednesday, June 29, 2022

Article Commentary: “Advances in Acute Ischemic Stroke Therapy”

This barely suggests that they know that thrombolysis or thrombectomy is only the first step in needed stroke interventions to get to 100% RECOVERY. But they are using the tyranny of low expectations(reperfusion) to declare success. In my opinion this is all still a failure because no one is trying for 100% recovery.

Article Commentary: “Advances in Acute Ischemic Stroke Therapy”

Ayush Agarwal, MD, DM, DNB
@drayushagarwal

Xiong Y, Wakhloo AK, Fisher M. Advances in Acute Ischemic Stroke Therapy. Circulation Research. 2022;130:1230–1251.

The management(This is the whole problem right here. Survivors want recovery, NOT 'MANAGEMENT'! Words matter.) of acute ischemic stroke continues to progress(REALLY? I SEE NOTHING!), and there is a shift towards ‘tissue window’ from the traditional ‘time window.’ Recent trials have demonstrated that thrombolysis can safely be done out of the traditional time window based on careful patient selection using advanced imaging techniques including brain MRI and CT-perfusion (1,2). Although, traditionally, alteplase has been the mainstay of treatment, tenecteplase usage is rapidly gaining ground based on ease of administration and higher fibrin specificity. It has not only been proven non-inferior, but also better at lysing large vessel clots (when compared to alteplase) (3). The advent of mobile stroke units with CT scanners and point-of-care laboratory support has further reduced door-to-needle times and led to even better stroke outcomes (4,5).

Endovascular thrombectomy (EVT) can also now be performed up to 24 hours after symptom onset in a select patient population (6,7). The AURORA meta-analysis showed that the treatment effect of endovascular thrombectomy was stronger for patients randomized between 12-24 hours compared to those randomized between 6-12 hours. There was no significant difference in clinical outcomes between patients undergoing EVT based on the use of general anesthesia or conscious sedation.

No definitive answers could be provided on skipping intravenous thrombolysis and doing direct EVT in patients with large vessel occlusions (LVO) (8–10). Therefore, the current evidence does not support skipping thrombolysis as bridging therapy prior to EVT.

Cytoprotection therapy may actually have a role to play as opposed to ‘neuroprotection’, as neurons are not the only injured neurological cell type during ischemia. Cytoprotection entails targeting multiple aspects of the ischemic cascade and prescription when documented salvageable penumbra is present. Numerous trials are underway based on this understanding.

References:

1. Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, et al. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. N Engl J Med. 2018;379:611–22.

2. Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, et al. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. N Engl J Med. 2019;380:1795–803.

3. Campbell BCV, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018;378:1573–82.

4. Ebinger M, Siegerink B, Kunz A, Wendt M, Weber JE, Schwabauer E, et al. Association Between Dispatch of Mobile Stroke Units and Functional Outcomes Among Patients With Acute Ischemic Stroke in Berlin. JAMA. 2021;325:454–66.

5. Grotta JC, Yamal JM, Parker SA, Rajan SS, Gonzales NR, Jones WJ, et al. Prospective, Multicenter, Controlled Trial of Mobile Stroke Units. N Engl J Med. 2021;385:971–81.

6. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018;378:11–21.

7. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378:708–18.

8. LeCouffe NE, Kappelhof M, Treurniet KM, Rinkel LA, Bruggeman AE, Berkhemer OA, et al. A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke. N Engl J Med. 2021;385:1833–44.

9. Yang P, Zhang Y, Zhang L, Zhang Y, Treurniet KM, Chen W, et al. Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke. N Engl J Med. 2020;382:1981–93.

10. Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, et al. Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial. JAMA. 2021;325:244–53.