Setareh Omran, MD Vascular Neurology Fellow

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Presentation transcript:

Setareh Omran, MD Vascular Neurology Fellow

2013 guidelines: door-to-CT 25 mins Used to be 25 mins at our hospital

Systematic review and meta-analysis of 8 studies of 2,601 stroke patients total, receiving IV thrombolysis with pre-treatment MRI, outcome being sICH and 3-6 mo poor functional outcome (>2 mRS). CMB seen on one quarter of MRIs, associated with higher risk of sICH compared to patients without CMB (OR 2.18; 95 CI 1.12-4.22; p=0.021). Poor functional outcome was more common in patients with CMB (OR 1.6 (95% CI, 1.18 – 2.14; p=0.002) compared to no CMB.

Meta-analysis of 9 studies examining the rate of sICH complicating IV tPA in patients with AIS with pre-treatment MRI. CMB rated as 0 (absent), 1+ (CMB presence). 1-10 CMBs = low to moderate CMB burden. >10 CMB = high CMB burden Outcome was sICH based on ECASS II criteria. Included 2479 patients total. Risk of sICH after IV tPA was higher in patients with CMB presence (RR 2.36, p=0.01), with higher risk in patients with high CMB burden compared to 0-10 CMB (RR 12.10, p<0.001) and 1-10 CMB (RR 7.01, P<0.001).

Logallo et al, Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomized, open-label, blinded endpoint trial. The Lancet Neurology, Oct 1, 2017. Superiority trial, done in 13 stroke units in Norway. Included patients presenting within 4.5hr LKN, randomly assigned 1:1, clinicians not blinded to treatment but outcome assessors were blinded. Primary outcome: mRS 0-1 at 3 mo. ITT model. Included 1100 patients, mean NIHSS 4 (IQR 2-8). Tenecteplase was not found to be superior to alteplase: OR 1.1 (95% CI 0.8-1.4), no difference in ICH/safety profile.

DAWN versus DEFUSE 3 eligibility criteria: DEFUSE 3: 6-16 hours LKN, NIHSS greater than or equal to 6, mRS 0-2 at baseline, proximal MCA (M1) or ICA occlusion, infarct size <70ml by CTP (RAPID) or MRI-DWI, ratio of volume of ischemic to infarct of 1.8 or more. Outcome was mRS at 90d. DAWN: 6-24 hours LKN, NIHSS greater than or equal to 10, mRS 0-2 at baseline, proximal MCA (M1 + maybe M2) or ICA occlusion, infarct size 0-20ml if >80 yo, 0-30ml if NIHSS >10 or 0-50ml if NIHSS >20. Outcome was mRS at 90d.

Outcome being stroke recurrence at 90d. HR (0. 68, 95% CI, 0. 57 -0 Outcome being stroke recurrence at 90d. HR (0.68, 95% CI, 0.57 -0.81; p<0.001). Follow up at 1yr: 2.1% lost to follow up. Patients in DAPT therapy x21d arm had lower rate of ischemic stroke, no difference in hemorrhagic rate at 1yr. Greatest benefit shown to be within first 90d. After 90 days, similar rate of stroke between two arms (HR 0.96; 95% CI 0.68-1.35; p=0.81).

Done in UK. Studied cost-effectiveness of MRI including DWI in patients with TIA and minor strokes. Pooled analysis of 30,558 patients with TIA or minor strokes. MR DWI showed an ischemic lesion in 34% of patients, remainder being DWI negative. UK survey showed most secondary prevention started prior to clinic, but MRI was usually obtained an average of one week after LKN. Compared to CT scan, MRI was more expensive and no more cost-effective, except for patients presenting >1wk from symptom onset (diagnosing hemorrhage). One-stop CT/MRI was not effective.

Included 2125 patients with acute cerebral infarcts on MRI-DWI between 2006-2013 in Norway – 187 (8.8%) had multifocal cerebral infarcts. Found an association between multifocal infarcts and cardioembolism and afib, ICA stenosis. In logistic regression, found that cardiac embolism and symptomatic ICA stenosis were independently associated with multifocal infarcts (?adjudicated outcomes).

Pattern of acute multifocal infarcts has a positive LR of 1 Pattern of acute multifocal infarcts has a positive LR of 1.41, negative LR 0.96 for cardioembolic stroke, and a positive LR of 1.18 and negative LR of 0.98 for detection of afib.

CRYSTAL AF: Randomized, controlled, n=441 with no afib on 24hr tele - LTCM with ICM vs standard. End point was time to detection of afib at 6, 12 mo. Results: afib was detected more in ICM arm than control, statistically significant (6.4; 95% CI 1.9-21.7). Follow up study at 3 years – large loss to follow up (441 pts to 48), with mean follow up time of 20 months. Afib detected in 30% of patients in ICM arm vs 3% in control. Find-AF randomised: Open label randomized trial done in Germany, 398 patients total, compared 10d Holter monitoring at baseline, 3, 6 mo to standard care. Most were cardioembolic or cryptogenic strokes. Found absolute difference 9% of detecting afib (number needed to screen =11). No difference in stroke recurrence in either arm at 12 mo (3.7 vs 5.4%, P=0.46).

Assigned patients with moderate-to-severe OSA and coronary or cerebrovascular disease to receive CPAP vs standard care. Primary end point was death from cardiovascular causes, including MI and stroke. Found no difference in death from cardiovascular causes, and no difference in rate of stroke in both arms (HR 0.97, 95% CI 0.69-1.35; p=0.84).

Thank you!