Treatment of ischaemic/haemorrhagic stroke Flashcards
what types of hyperacute treatments are there
iv thrombolysis
mechanical thrombectomy
what trials show iv thrombolysis
NINDS trial 1996
Cochrane review
ECASS-3
IST-3
what happened in the NINDS-2 trial?
tPA or placebo given within 3 hours
favourable outcome at 3 months - 4 statistic including mRankin scale
what happened in the Cochrane review 2003
18 trials, 5727 patients 4 agents: rtPA (50%), SK, UK, rpUK fewer patients dead or dependent more deaths in first 7-10 days rtPA possibly less hazard and more benefit
what happened in ECASS-3: 3-4half hours?
european trial
MINDS trial repeated with same inclusion/exclusion criteria but different time window
what happened in IST-3
biggest trial of intravenous throm
ran for many years
looked at group of patients not eligible for standard thrombolysis. a study of the patients who could not be thrombolysed routinely older patients >80
what happened in the wake-up trial
2018 sweden trial
patients with unknown time of onset
last known well > 4.5hr ago
stroke < 4.5 hr ago
within minutes of stroke happening, infarction on brain shows up very bright on dwi
flair signal takes about 4.5 hrs to develop
results: 503 patients, favourable outcome in 53.3%
what happened in the EXTEND trial
4.5 to 9hr after stroke onset or woke within 9hr of midpoint of sleep
Perfusion mismatch - CT or MR perfusion. 225 of planned 310 patients enrolled. stopped early
how is IV tPA given now
within 4.5 hrs, rapid plain CT
see if safe to give thromolysis
ct/mr perfusion to look for mis match and how much brain to save.
known onset beyond 4.5-9 hrs - small sub-group who may still benefit
what happened in IMS-3 trial
in 2013. IV tPA and endovascular vs only IV tPA as treatment.
IV tPA given within 3 hours of stroke onset
trial was stopped
negative trials
IMS-33, synthesis-expansion, MR-RESCUE
new devices for treatment
penumbra
solitaire
what happened in MR CLEAN trial
in 2015. Dutch study.
500 patients in 16 centres. assessed intra-arterial vs standard care. MT or ia tPD
carotid-T, M1, M2, A1, A2 occlusion
89% had iv tPA before randomisation
there was a long time window between tPA given and when randomised
what happened in ESCAPE 2015 trial
stopped for efficacy
analysis at 300 but planned sample size 500 but unplanned interim analysis at 315 because of MR CLEAN
ESCAPE protocol
good pre-morbid state enrollment up to 12hr post-stroke CT and CTA (multiphase preferred) small core infarct M1 or M2 occlusion moderate to good collaterals on CTA
what happened in EXTEND-IA 2015
tPA candidates only (4.5 hr window) M1/M2 occlusions endovascular within 6 hr CT perfusion for salvageable tissue planned for 100 patients but stopped for efficacy after 70 patients. unplanned analysis after MR CLEAN
what happened in SWIFT-PRIME 2015
initially using CT perfusion
changed to using ASPECTS > 7
what happened in REVASCAT 2015
206 patients from Catalonia
ASPECTS > 7
Name 2 studies in 2016
THRACE 2016
PISTE 2016
what happened in DAWN
206 patients
pre stroke mRS 0-1
terminal ICA, or M1 occlusion
9% given tPA
infarct volume on DWI or CTP
assess penumbra by looking at patient see how much brain threatened by infarction
use imaging to establish core patient with big stroke but small core
showed 73% relative risk reduction of dependency in ADLs NNT for any lower disability 2.0
what happened in DEFUSE-3
pre-stroke mRS 0-2 NIHSS > 6 at randomisation 6-16 hrs from onset not given iv tPA terminal ICA or M1 occlusion core < 70ml penumbra > 15 ml total ischaemic vol > 1.8
other ways to try treatment
tenecteplase (modified from tPA) given as single injection –> 3 trials: ATTEST-2, TWIST, TEMPO-2
therapeutic cooling
spinning iron microbeads
what happened in Vahedi et al 2007
clincally MCA infarct of NIHSS
CT infarct > 50% of MCA territory
what happened in interact 2
primary ICH and sBP 150-220
not comatose
intensive BP lowering vs standard
what happened in TICH-2
patients with primary ICH
tranexamic acid vs placebo
treatment within 8 hrs of onset
dead or dependent at 90 days
