Tag Archives: International Stroke Conference

Revolutionizing Ischemic Brain Management, at a Stroke

When Dr. Jeffrey Saver announced last week at the International Stroke Conference that treatment of acute, ischemic stroke patients with the Solitaire retrievable stent produced a 61% rate of complete recanalization, he predicted that this landmark result would quickly propel acute stroke management into a new era.

It sounds a bit audacious for the results of a study with 113 randomized patients to change the face of U.S. management of acute, ischemic stroke patients, but Dr. Saver laid out a compelling scenario at the meeting. In essence, it’s the right result for the right device at the right time.

MRI head scan/courtesy Wikimedia Commons/Ranveig Thattai/creative commons license

Acute stroke care in America is already poised at an important threshold. Last week, The Joint Commission, the U.S. organization responsible for accrediting health-care institutions, announced their newly crafted criteria for credentialing Comprehensive Stroke Centers. By next year, Dr. Saver predicted, 100-200 such centers will have received this designation into the highest tier of acute stroke management. He expects all these locations to treat patients with the Solitaire stent, as well as a few others. “At least 250” U.S. sites should be using it within the next couple of years, he told me. In addition, an emergency-medicine culture already exists to ambulance acute stroke patients to one of the 1,000 Primary Stroke Centers that now exist in America, use imaging to identify the ones who qualify for intravenous lytic therapy with tissue plasminogen activator (t-PA), start administering the drug, and then transfer them to a center that can apply more advanced care, a strategy know as “drip and ship.”

Having the Solitaire device takes this approach a step further, making it “drip, ship, and grip,” he told me, with grip being the step when the thrombus causing the stroke is engaged and removed.

“We stand poised at a new era, our first experience with highly effective cerebral revascularization,” he said at the meeting last week. “The open secret in our field is that t-PA or the devices now available deliver treatment that fails most of the time.” Intravenous t-PA by itself produces full recanalization in about 5% of patients, while existing devices up this to 25%; for Solitaire the rate was 61% in the new randomized study, and the rate of full or partial recanalization was 83%.

This new level of success with Solitaire will make a big difference in how widely the treatment gets used, he told me.

Dr. Jeffrey Saver MITCHEL ZOLER/Zoler/Elsevier Global Medical News

“I think motivations [to use endovascular interventions] will shift with a more reliable device. That will drive wider uptake.” He called it a “paradigm shift” and a “game changer.”

Rapid application of effective endovascular therapy “was the vision of acute stroke care that was a hazy dream when I first became a stroke neurologist 20 years ago,” Dr. Saver said. “I think that in the next few months and years it will become the reality.”

—Mitchel Zoler (on Twitter @mitchelzoler)

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Brain Imaging May Expand Stroke Treatment

Using MRI to look at the brains of people who’ve had a stroke but who can’t tell when the stroke began might help identify those who could safely be treated. Approximately 25% of ischemic strokes occur in people who don’t know, or are unable to communicate, when their stroke began. That usually makes them ineligible for thrombolytic therapy, which must be given within 4.5 hours of the onset of stroke symptoms, according to treatment guidelines.

A preliminary study of 430 patients with unclear-onset stroke used MRI to select 19 patients who were thought to be within that treatment window, Dr. Dong-Wha Kang of the University of Usan, Seoul, South Korea reported at the International Stroke Conference. Treating those 19 resulted in a good clinical outcome in 37 (45%), which Dr. Kang said is encouraging enough to justify further studies of this approach.

He showed three examples of MRIs to illustrate how they selected patients for treatment. The first image shows no mismatch between brain lesions viewed on diffusion-weighted imaging (DWI) or fluid-attenuated inversion-recovery (FLAIR) MRI. This patient was considered a poor candidate for treatment and was not enrolled in the study.

The second image shows a partial FLAIR change within the DWI lesion and a perfusion-diffusion mismatch. This patient was eligible for treatment.

All images courtesy Dr. Dong-Wha Kang.

The third image shows a large perfusion-diffusion mismatch and no FLAIR changes within the DWI lesion, making this a good candidate for treatment in the study.

Everyone agrees the study wasn’t strong enough to change clinical practice, and reasons for wanting further studies differed. Some were encouraged and want more studies to see if this approach pans out. Others were skeptical and want more studies to prove that there’s really something of value here besides pretty images.

Hear Dr. Mark Alberts, professor of neurology and director of the stroke program at Northwestern University, commenting on the study in a  minute-and-a-half podcast  provided by the American Heart Association and the American Stroke Association (sponsors of the conference).

And learn more from my full story and video.

— Sherry Boschert (@sherryboschert on Twitter)

 

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Filed under Emergency Medicine, Family Medicine, Geriatric Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Neurology and Neurological Surgery, Polls

Does ‘Stroke Center’ Label Improve Care?

I heard an interesting debate at the International Stroke Conference about whether or not having a “Stroke Center” designation improves outcomes for patients with stroke. What made it even more interesting is that the debater arguing against this idea is director of a certified Stroke Center.

The Joint Commission, in collaboration with the American Heart Association and the America Stroke Association, developed certification criteria and started designating qualified medical centers as Primary Stroke Centers beginning in December 2003. The idea was to recognize centers that could provide superior care for people with acute ischemic stroke and motivate other centers to reach for this level of excellence.

There are now more than 800 certified Primary Stroke Centers in 49 states. Here’s a list, and more info on Stroke Centers. Have patient outcomes after stroke improved because of all this?

Dr. Mark J. Alberts Image courtesy Northwestern University

Dr. Mark J. Alberts, director of the stroke program at Northwestern University, Chicago, cited lots of evidence over many years showing higher rates of using clot-busting drugs, lower death rates, and less need for institutionalization when patients were treated in stroke units compared with other hospital care. Impressive.

Dr. S. Claiborne Johnston Image by Sherry Boschert

 

Most of that data, however, came from studies conducted before The Joint Commission started handing out the Stroke Center designation, noted Dr. S. Claiborne Johnston, director of the stroke service at the University of California, San Francisco. He agreed that care is better at Primary Stroke Centers, but argued that these were the centers that already were excelling at stroke care and working hard to improve stroke care, and so they applied for and earned the Primary Stroke Center labels. There’s no evidence that the label itself improved outcomes at those centers.

I suppose Dr. Johnston won the debate on a verbal technicality. But he graciously posed a different question that probably everyone could agree upon: Does society benefit from Stroke Center certifications? It sure seems so. Because of Stroke Center certification, emergency medical services teams steer ambulances toward Stroke Centers and bypass non-certified hospitals when they have a patient with stroke on board. By providing a framework for regionalization of care, the Stroke Center designation helps get patients to hospitals that provide better stroke care, improving outcomes on a society-wide level.

–Sherry Boschert

(Follow me on Twitter @sherryboschert)

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Filed under Cardiovascular Medicine, Emergency Medicine, Family Medicine, Geriatric Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Neurology and Neurological Surgery, Uncategorized

Imaging Resets the Stroke Clock

from the International Stroke Conference in San Antonio

Until recently, acute stoke treatment ran strictly by the clock. Now that’s changing.

image courtesy Flickr user teh kankaik

First line treatment, intravenous infusion of a clot-disolving drug like tissue plasminogen activator (tPA), initially had a 3 hour time window, recently pushed back to 4.5 hours. More aggressive, endovascular treatments aimed at removing blood-blocking clots–intra-arterial tPA, the Merci clot retriever, and the Penumbra clot suction device–have received time limits of 6 hours (for intra-arterial tPA) or 8 hours (for the mechanical devices).

But interventional neurologists at several U.S. stroke centers now use these treatments beyond the 8 hour limit on selected patients, those with enough salvageable brain when assessed by perfusion CT or by diffusion-weighted MRI.

This approach received a boost at the Stroke meeting last week, when a review of 237 patients selected this way showed that encovascular reperfusion treatments were safe and effective for many patients who started on treatment anywhere from 8-111 hours after their stroke began.

“A lot of patients are deprived treatment based on time,” said Harvard neurologist Raul G. Nogueira, who reported the results. “It’s time to get away from the time window. No question that sooner is better, but some patients benefit later.”

Dr. Nogueria acknowledged the next step is to prove this in the prospective study now being assembled. In the meantime, his findings give some validation to a practice that’s become routine at many U.S. stroke centers.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Age Effect Missed in Many CREST Carotid-Treatment News Reports

from the International Stroke Conference in San Antonio 

The headline message from the CREST study reported at the stroke meeting last Friday was that two different revascularization procedures for severe carotid artery stenosis–carotid stenting and carotid endarterectomy–were equally safe and effective.  This oversimplification was true only if all of the patients undergoing these treatments were 70 years old. 

The reality was that while, on average, the two procedures had very similar results, the study also showed a powerful age effect that led to substantially different outcomes depending on patient’s age. 

Here is the graphic presented on Friday that showed this relationship: 

photo by Mitchel Zoler

The dark solid line follows the changing relationship between patient age and the relative benefit (less than 1.0) or relative harm (more than 1.0) from carotid artery stenting (CAS) compared with carotid endarterectomy (CEA). 

Patients younger than 70 who underwent stenting had fewer adverse events–the combined rate of death, stroke, or myocardial infarction–than patients who underwent carotid endarterectomy. At age 60, the relative rate of adverse events with carotid stenting was roughly 35% below that of 60-year old patients who underwent endarterectomy. At age 50, the relative rate of adverse events was cut by more than half by stenting. 

The situation flipped for patients older than 70. At age 80, patients treated by stenting had a greater than 50% higher rate of adverse events than those treated with endarterectomy. 

News reports that simply said the two treatments had similar outcomes missed this key CREST finding. 

My full report on the CREST results is here.

—Mitchel Zoler (on Twitter @mitchelzoler) 

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