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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.
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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.
Written by Alex Clark Spoon FeedIn 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. Let me get this straight… DAPT is not, not, not worse than tPA?Current guidelines recommend thrombolytics for AIS patients presenting within …
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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.
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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.
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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
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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.
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Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion. N Engl J Med. 2022 Oct 13;387(15):1361-1372. doi: 10.1056/NEJMoa2206317.
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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.
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Tenecteplase, at a dose of 0.4 mg/kg, is not safe for patients with moderate to severe ischemic stroke.
Source
Tenecteplase versus alteplase for the management of acute ischaemic stroke in Norway (NOR-TEST 2, part A): a phase 3, randomised, open-label, blinded endpoint, non-inferiority trial. Lancet Neurol. 2022 Jun;21(6):511-519. doi: 10.1016/S1474-4422(22)00124-7. Epub 2022 May 4.
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There was no significant difference in intracranial hemorrhage, serious systemic hemorrhage, or inpatient mortality for patients who used non-vitamin K oral anticoagulants in the seven days prior to receiving alteplase for acute ischemic stroke.
Source
Association of Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants With Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA. 2022 Feb 22;327(8):760-771. doi: 10.1001/jama.2022.0948.
