Ethics Week – COI and Stroke Guidelines
There is some concern for financial conflict of interest among guideline authors for the AHA stroke guidelines. However, just 6% (2/34) of the authors for the 2013 or 2018 AHA guidelines had industry ties related to alteplase in the year of publication. Be sure to read the more nuanced discussion.
EXTEND – Alteplase Up to 9 Hours Out?
Use of alteplase from 4.5 to 9 hours in patients with ischemic stroke but with salvageable brain on perfusion imaging was superior to placebo (aRR 1.44, 95%CI 1.01-2.06; NNT = 17). Symptomatic hemorrhage was more common in the alteplase group.
Review – Endovascular Stroke Treatment
Endovascular therapy (EVT) for acute ischemic stroke can dramatically improve outcome. This review helps us makes sense of the trials on this topic.
Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage
The table below summarizes the recommendations for adult patients on anti-thrombotic agents with intracranial hemorrhage (both spontaneous and traumatic). This will be focused on ED management.
The Sweet Spot for BP in ICH
For patients with acute intracerebral hemorrhage (ICH), intensive lowering of systolic blood pressure (SBP) with goal SBP < 140 mmHg was associated with increased cerebral ischemia and neurologic deterioration compared to goal SBP < 160 mmHg.
Lytics for Mild Stroke Disastrous
Not surprisingly, patients with mild, non-disabling stroke did not benefit from receiving alteplase over aspirin. If anything, the trend favored aspirin. Five patients (3.2%) who received alteplase had intracranial hemorrhage.
Door to tPA Under 20 Minutes – Impressive or Dangerous?
A door-to-tPA in under 20 minute protocol at this center with 1015 stroke alerts resulted in a misdiagnosis rate of 14.8% and 8 people being harmed. The authors concluded this was safe. I'm not so sure about that.
PE and Stroke Risk for Transgender Patients
Transfeminine patients had nearly doubled risk for venous thromboembolism (VTE). The risk tripled for VTE and doubled for stroke if taking hormone supplementation.
Timing of Stroke After Blunt Cerebrovascular Dissection
Most strokes from blunt cerebrovascular injury (BCVI) occurred at a median time of 48 hours. If other injuries allow it, the earlier antithrombotic therapy can be started, the better for preventing stroke.
Weekend Brain #FOAMed
If you want to go deeper on stroke, may I suggest this in-depth review by emDocs or a shorter version that Thomas Davis did on JF? Also emDocs has an outstanding post on concussion. From the sideline to the ED to return-to-play, this brief but comprehensive post is stuff we need to know.