Use the labels in the right column to find what you want. Or you can go thru them one by one, there are only 34,155 posts. Searching is done in the search box in upper left corner. I blog on anything to do with stroke. DO NOT DO ANYTHING SUGGESTED HERE AS I AM NOT MEDICALLY TRAINED, YOUR DOCTOR IS, LISTEN TO THEM. BUT I BET THEY DON'T KNOW HOW TO GET YOU 100% RECOVERED. I DON'T EITHER BUT HAVE PLENTY OF QUESTIONS FOR YOUR DOCTOR TO ANSWER.
Changing stroke rehab and research worldwide now.Time is Brain!trillions and trillions of neuronsthatDIEeach day because there areNOeffective 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.
In patients with acute large vessel occlusion, the natural history of penumbral tissue based on perfusion time-to-maximum (Tmax)
delay is not well established in relation to late-window endovascular
thrombectomy. In this study, we sought to evaluate penumbra consumption
rates for Tmax delays in patients with large vessel occlusion evaluated between 6 and 16 hours from last known normal.
Methods:
This
is a post hoc analysis of the DEFUSE 3 trial (The Endovascular Therapy
Following Imaging Evaluation for Ischemic Stroke), which included
patients with an acute ischemic stroke due to anterior circulation
occlusion within 6 to 16 hours of last known normal. The primary outcome
is percentage penumbra consumption, defined as (24-hour magnetic
resonance imaging infarct volume–baseline core infarct volume)/(Tmax
6 or 10 s volume–baseline core volume). We stratified the cohort into 4
categories based on treatment modality and Thrombolysis in Cerebral
Infarction (TICI score; untreated, TICI 0-2a, TICI 2b, and TICI3) and
calculated penumbral consumption rates in each category.
Results:
We
included 141 patients, among whom 68 were untreated. In the untreated
versus TICI 3 patients, a median (interquartile range) of 53.7%
(21.2%–87.7%) versus 5.3% (1.1%–14.6%) of penumbral tissue was consumed
based on Tmax >6 s (P<0.001). In the same comparison for Tmax>10 s, we saw a difference of 165.4% (interquartile range, 56.1%–479.8%) versus 25.7% (interquartile range, 3.2%–72.1%; P<0.001).
Significant differences were not demonstrated between untreated and
TICI 0-2a patients for penumbral consumption based on Tmax >6 s (P=0.52) or Tmax >10 s (P=0.92).
Conclusions:
Among extended window endovascular thrombectomy patients, Tmax >10-s mismatch volume may comprise large volumes of salvageable tissue, whereas nearly half the Tmax >6-s mismatch volume may remain viable in untreated patients at 24 hours.
Useless crap. They don't even bother to tell us how many got fully recovered. And using the subjective Rankin scale for measuring anything is stroke in worthless. Comparing failures and suggesting those outcomes are ok is not the way research should be done.
Educational Objective To determine whether patients with
ischemic stroke with large-vessel occlusion in the anterior circulation
who were transferred from outside facilities for endovascular
thrombectomy have similar outcomes(So the comparison is to failure to fully recover?) in the late window compared with
patients who were directly admitted to thrombectomy-capable hospitals.
QuestionDo patients with ischemic stroke with large-vessel occlusion
in the anterior circulation who were transferred from outside facilities
and had penumbral imaging mismatch prior to endovascular thrombectomy
have similar outcomes with thrombectomy in the late window as those who
were directly admitted to thrombectomy-capable hospitals? FindingsIn this secondary analysis of a randomized clinical trial,
transfer and direct patients had comparable rates of functional
independence(How many got 100% recovered? THAT IS THE CORRECT ENDPOINT. Not the tyranny of low expectations you want us to accept.) and similar treatment effect with endovascular thrombectomy
as well as similar symptomatic intracranial hemorrhage and mortality. MeaningTransferring patients for late-window thrombectomy may be
associated with substantial clinical benefits and should be encouraged.
Abstract
ImportanceAlthough thrombectomy benefit was maintained in transfer
patients with ischemic stroke in early-window trials, overall functional
independence rates were lower in thrombectomy and medical
management–only groups. ObjectiveTo evaluate whether the imaging-based selection criteria used
in the Endovascular Therapy Following Imaging Evaluation for Ischemic
Stroke 3 (DEFUSE 3) trial would lead to comparable outcome rates and
treatment benefits in transfer vs direct-admission patients. Design, Setting, and ParticipantsSubgroup analysis of DEFUSE 3, a prospective, randomized,
multicenter, blinded–end point trial. Patients were enrolled between May
2016 and May 2017 and were followed up for 90 days. The trial comprised
38 stroke centers in the United States and 182 patients with stroke
with a large-vessel anterior circulation occlusion and initial infarct
volume of less than 70 mL, mismatch ratio of at least 1.8, and mismatch
volume of at least 15 mL, treated within 6 to 16 hours from last known
well. Patients were stratified based on whether they presented directly
to the study site or were transferred from a primary center. Data were
analyzed between July 2018 and October 2018. Interventions or ExposuresEndovascular thrombectomy plus standard medical therapy vs standard medical therapy alone. Main Outcomes and MeasuresThe primary outcome was the distribution of 90-day modified Rankin Scale scores. ResultsOf the 296 patients who consented, 182 patients were
randomized (66% were transfer patients and 34% directly presented to a
study site). Median age was 71 years (interquartile range [IQR], 60-79
years) vs 70 years (IQR, 59-80 years); 69 transfer patients were women
(57%) and 23 of the direct group were women (37%). Transfer patients had
longer median times from last known well to study site arrival (9.43 vs
9 hours) and more favorable collateral profiles (based on hypoperfusion
intensity ratio): median for transfer, 0.35 (IQR, 0.18-0.47) vs 0.42
(IQR, 0.25-0.56) for direct (P = .05). The primary outcome
(90-day modified Rankin Scale score shift) did not differ in the direct
vs transfer groups (direct OR, 2.9; 95% CI, 1.2-7.2; P = .01; transfer OR, 2.6; 95% CI, 1.3-4.8; P = .009).
The overall functional independence rate (90-day modified Rankin Scale
score 0-2) in the thrombectomy group did not differ (direct 44% vs
transfer 45%) nor did the treatment effect (direct OR, 2.0; 95% CI,
0.9-4.4 vs transfer OR, 3.1; 95% CI, 1.6-6.1). Thrombectomy reperfusion
rates, mortality, and symptomatic intracranial hemorrhage rates did not
differ. Conclusions and RelevanceIn late-window patients selected by penumbral mismatch
criteria, both the favorable outcome rate and treatment effect did not
decline in transfer patients. These results have health care
implications indicating transferring potential candidates for
late-window thrombectomy is associated with substantial clinical
benefits and should be encouraged. Trial RegistrationClinicalTrials.gov identifier: NCT02586415
Advances in brain imaging can identify a greater number of stroke
patients who can receive therapy later than previously believed,
according to a new study. The results of the Endovascular Therapy
Following Imaging Evaluation for the Ischemic Stroke (DEFUSE 3) trial,
presented at the International Stroke Conference 2018 in Los Angeles and
published on Jan. 24 in the New England Journal of Medicine,
demonstrated that physically removing brain clots up to 16 hours after
symptom onset in selected patients led to improved outcomes compared to
standard medical therapy. The study was funded by the National Institute
of Neurological Disorders and Stroke (NINDS), part of the National
Institutes of Health.
"These striking results will have an immediate impact and save people
from life-long disability or death," said Walter Koroshetz, M.D.,
director NINDS. "I really cannot overstate the size of this effect. The
study shows that one out of three stroke patients who present with
at-risk brain tissue on their scans improve and some may walk out of the
hospital saved from what would otherwise have been a devastating brain
injury."
DEFUSE 3 was a large, multi-site study supported by NINDS' StrokeNet,
which is a network of hospitals providing research infrastructure for
multi-site clinical trials. This study was conducted at 38 centers
across the United States and was led by Gregory W. Albers, M.D.,
professor of neurology and neurological sciences at Stanford University
School of Medicine, in California, and director of the Stanford Stroke
Center. The study was ended early by the NIH on recommendation of the
independent Data and Safety and Monitoring Board because of overwhelming
evidence of benefit from the clot removal procedure.
Ischemic stroke occurs when a cerebral blood vessel becomes blocked,
cutting off the delivery of oxygen and nutrients to brain tissue. Brain
tissue in the immediate area of the blockage, known as the core, cannot
typically be saved from dying, and it can enlarge over time. However, it
has long been thought that the area surrounding the core (known as the
ischemic penumbra) has the potential to be saved based on how quickly
the blood flow can be restored. Over the past two decades, scientists
have been working to develop brain scanning methods, called perfusion
imaging, that could identify patients with brain tissue that can still
be salvaged by removing the blockage. In perfusion imaging, a standard
dye is injected and scanned for a few minutes as it passes through the
brain.
Using
an automated software known as RAPID to analyze perfusion MRI or CT
scans, the DEFUSE 3 researchers identified patients thought to have
salvageable tissue up to 16 hours after stroke onset. The participants
were randomized to either receive endovascular thrombectomy plus
standard medical therapy or medical therapy alone.
Endovascular thrombectomy, or the physical removal of the blockage,
is currently approved for use up to six hours following onset of stroke
symptoms. Dr. Albers and the DEFUSE 3 researchers discovered that this
intervention can be effective up to 16 hours after symptoms begin in
this select group of patients. The findings showed that patients in the
thrombectomy group had substantially better outcomes 90 days after
treatment compared to those in the control group. For example, 45
percent of the patients treated with the clot removal procedure achieved
functional independence compared to 17 percent in the control group. In
addition, thrombectomy was associated with improved survival. According
to the results 14 percent of the treated group had died within 90 days
of the study, compared to 26 percent in the control group.
"Although stroke is a medical emergency that should be treated as
soon as possible, DEFUSE 3 opens the door to treatment even for some
patients who wake up with a stroke or arrive at the hospital many hours
after their initial symptoms," said Dr. Albers.
DEFUSE 3 builds on results from the two earlier DEFUSE studies as
well as the industry-sponsored DAWN trial, which used perfusion imaging
technology to identify patients most likely to benefit from
interventions such as thrombectomy. Those studies suggested that the
advanced brain imaging could identify which patients could benefit from
restoring blood flow in an extended treatment window.
Well shit, the answer is to write up protocols and modify them as needed. But we also need to know exactly the time parameters that provide 100% recovery for each type of intervention. Without that we will never provide correct solutions. https://www.medpagetoday.com/meetingcoverage/isc/70827?
Stroke docs struggle with message after DAWN, DEFUSE 3, new guidelines
Note that this study was
published as an abstract and presented at a conference. These data and
conclusions should be considered to be preliminary until published in a
peer-reviewed journal.
LOS
ANGELES -- Time is brain has been a hard-fought mantra in acute stroke
care. Decades after introduction of IV thrombolysis, the still-slow
climb in rates of use show just how difficult.
The time-focused message is butting up against the DEFUSE 3 and DAWN trials,
showing that a mechanical thrombectomy treatment window out to 16 and
even 24 hours still can benefit imaging-selected patients, and
newly-released American Heart Association/American Stroke Association guidelines officially promoting that extended window.
A subanalysis of DEFUSE 3 presented after the main results at the International Stroke Conference
(ISC) here showed just how unimportant time was for thrombectomy
outcomes when patients presented beyond 6 hours were selected with
perfusion imaging.
Whereas the likelihood of good functional outcome (modified Rankin
Scale score 0-2) dropped precipitously as time at presentation increased
from 6 hours to 16 in that trial among patients in the medical
treatment-only arm, the mechanical thrombectomy arm saw exactly the same likelihood of functional independence at hour 6 as at 16.
The discussion immediately turned to how to manage the interpretation.
"How do we as practitioners manage the messaging around it? Because
it could foster some complacency a little bit. You don't want any
complacency," said Bruce Ovbiagle, MD, of the Medical University of
South Carolina in Charleston, who chaired a press conference where the
findings were presented. "We've been pushing that for a long time. We
don't want to dilute our message in any way."
"We certainly don't want to give the message that it's okay to delay
treatment, that it's okay to delay coming to the hospital," agreed
Maarten Lansberg, MD, of Stanford University in Stanford, California,
who presented the substudy. "The message here is time is still
important; it is not too late when it's 6 hours. Even at 16 hours and
probably up to 24 hours, there is still a subset of the population
that's going to benefit."
Gregory Albers, MD, also of Stanford, presented the main DEFUSE 3 results
at ISC, and said that the extended-window thrombectomy studies provide
the next evolution in stroke beyond a simple time is brain mantra.
That mantra gained urgency with the approval of tissue plasminogen
activator (tPA) in 1996 with just a 3-hour window. But as imaging
developed in the 1990s, it also became clear that strokes developed
uniquely -- some patients who came in immediately after symptom onset
had massive infarcts whereas others remained small hours after onset.
In 2006, the first DEFUSE trial tested tPA out to 6 hours with MRI to
predict response. Albers' group developed the RAPID software to see how
much brain tissue is salvageable, which has been used in thrombectomy
trials to select patients for that treatment.
"With DAWN and DEFUSE [3], the world is moving from a time clock to a
tissue clock," commented Jeffrey Saver, MD, of the University of
California Los Angeles But, he clarified, "it's not longer just a time
clock, it's also a tissue clock."
Although imaging can find patients all along the time spectrum who
still have salvageable tissue that would stand to benefit, it's still
important to rush at every point along the line.
"The
time is still critical because a smaller percentage of the people you
check with that perfusion imaging will have that good brain," J Mocco,
MD, of Mount Sinai Hospital in New York City, said in panel discussion
at the DEFUSE 3 press conference. "But once you use the imaging to
select the patient, it's completely reasonable that they would have a
consistent treatment effect, because you've selected the ones that are
going to have that benefit."
After the imaging, "we still want everyone, even at 12 hours, to move
as fast as they can," Ralph Sacco, MD, of the University of Miami and
president of the American Academy of Neurology, told MedPage Today.
"In other studies, it is clearly shown that the longer it takes to open
the vessel, the worse the outcome. So we need to keep that message
going that time is brain, and that minutes count, and we need to get
these vessels open pretty quickly."
"The only good thing I think for the public is, when you wake up with
a stroke and you're out of that 6-hour time window, because last known
well was when you went to bed, there is now hope," he added.
The changing maxim also opens up more opportunities for research,
noted Ovbiagele. "What is it about these patients who, for whatever
reason, their strokes are developing more slowly as opposed to the
people who are developing rather quickly? People tend to say it's
collaterals; we continue to study that. But I think you have 50% [of
patients] with this who come in not eligible ... others somehow are
going slowly. I think it will be important for us to think about this."
DEFUSE 3 was funded by the National Institute of Neurological Disorders and Stroke.
Lansberg disclosed no relevant relationships with industry.
Albers
disclosed relevant relationships with iSchemaView, Medtronic outside
DEFUSE 3, and a patent licensed to Stanford University for automated
detection of arterial input function and venous output function voxels
in medical imaging.
Mocco disclosed a relevant relationships with Penumbra.
