NOAC + Stroke – Thrombolytic or Not?
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In this retrospective cohort study, there was no increased risk of intracranial hemorrhage, major bleeding, or in-hospital mortality in patients taking non-vitamin K antagonist oral anticoagulants compared to those not taking anticoagulants, but read the fine print.
TENSION RCT – Thrombectomy for Large-Infarct Volume Strokes
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Endovascular thrombectomy plus medical care is better than medical care for patients with large vessel occlusion (LVO), even with established large infarcts.
Source
Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet. 2023 Nov 11;402(10414):1753-1763. doi: 10.1016/S0140-6736(23)02032-9. Epub 2023 Oct 11. PMID: 37837989.
What’s the BEST Target SBP Post-Embolectomy for Stroke?
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More aggressive systolic blood pressure (SBP) goals, beyond keeping it <180 mmHg, probably don’t make much of a difference in outcomes for patients who have undergone endovascular therapy for ischemic stroke.
Source
Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial. JAMA. 2023 Sep 5;330(9):821-831. doi: 10.1001/jama.2023.14330.
New ACEP Clinical Policy on Acute Ischemic Stroke
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This ACEP Clinical Policy examined four specific clinical questions related to ED management of acute ischemic stroke, which are summarized below.
Dual Antiplatelets or Lytics for Minor Stroke?
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In minor acute ischemic stroke (AIS) patients presenting within 4.5 hours of onset, dual antiplatelet therapy (DAPT) is non-inferior to intravenous alteplase for excellent neurologic outcome at 90 days.
Source
Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial. JAMA. 2023 Jun 27;329(24):2135-2144. doi: 10.1001/jama.2023.7827.
TRACE-2 RCT – Tenecteplase vs Alteplase for Stroke
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Tenecteplase was non-inferior to alteplase in patients with acute ischemic stroke who were eligible for intravenous thrombolytic therapy but ineligible or refused endovascular thrombectomy.
Source
Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial. Lancet. 2023 Feb 8;S0140-6736(22)02600-9. doi: 10.1016/S0140-6736(22)02600-9. Online ahead of print.
SELECT2 RCT – Endovascular Thrombectomy for Large Ischemic Strokes
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Thrombectomy plus usual medical care in patients with a proximal large vessel occlusion (LVO), a large ischemic core, and last known well <24 hours from presentation improves functional outcomes compared to medical care alone.
Source
Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med. 2023 Feb 10. doi: 10.1056/NEJMoa2214403. Online ahead of print.
Concise Review of Lytics and Endovascular Therapy for ‘Wake Up’ Stroke
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In patients presenting with ‘wake-up’ strokes, endovascular therapy improves functional outcomes, while intravenous alteplase may also provide a small beneficial impact.
Source
What is the Efficacy and Safety of Intravenous Thrombolysis and Thrombectomy Among Patients With a Wake-Up Stroke?. Ann Emerg Med. 2022;80(2):165-167. doi:10.1016/j.annemergmed.2022.02.013
ATTENTION RCT – Thrombectomy Benefits Basilar Artery Occlusion Stroke?
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Endovascular thrombectomy was associated with improved functional neurologic outcomes compared to best medical care for patients with basilar-artery occlusion who presented within 12 hours of stroke onset. However, thrombectomy was also associated with significant procedural complications and an increased risk of intracranial hemorrhage.
Source
Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion. N Engl J Med. 2022 Oct 13;387(15):1361-1372. doi: 10.1056/NEJMoa2206317.
Accuracy of Neuroimaging for Dizziness – It’s Not Pretty
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We cannot rely on neuroimaging (CT, CTA, MRI or MRA) alone to effectively rule out stroke in patients presenting to the ED with acute dizziness or vertigo.