Category: Stroke

This article is just a retrospective, consecutive case series from Spain reporting outcomes and adverse events from mechanical thrombectomy in acute stroke.  Most of their patients are significantly disabled from their strokes, with NIHSS ranging from 12 to 20 – unlikely to have great outcomes – but 14% developed intraparenchymal hemorrhage and 25% were deceased at 90 days.  Six patients had vessel wall perforation from the thrombectomy device.

The key sentence is the last sentence:
“Clinical efficacy of this approach compared with standard medical therapy remains to be demonstrated in prospective, randomized controlled trials.”

When mortality is 25% here, and 33% at 90 days in MERCI, multi-MERCI, and Penumbra trials, I’m still not sure this strategy is quite ready for prime time.  They do report that 54% had a “good outcome”, but it’s interesting to see that “good outcome” in stroke trials has progressed from Rankin Scores of 0 or 1 in NINDS etc. to ≤2 in these new trials.  They  also don’t offer a lot of granularity in their outcomes data.

But, as usual, as long as there are authors out there who “receive consulting and speaker fees from Co-Axia, ev3, Concentric Medical, and Micrus,” we’ll keep seeing reports like this.

“Manual Aspiration Thrombectomy : Adjunctive Endovascular Recanalization Technique in Acute Stroke Interventions”
http://www.ncbi.nlm.nih.gov/pubmed/22382156

…if we extrapolate the results from this single-center study to the entire United States.

In Annals this month, a chart review of the “discordance” between the final neurologist “gold standard” diagnosis and the provisional Emergency Department diagnosis.  Apparently, in Cleveland, 36% of the patients receiving an initial diagnosis of transient ischemic attack in the Emergency Department are subsequently evaluated by a neurologist and given an alternative diagnosis.  As the authors note in their introduction, the diagnosis of TIA is made 300,000 yearly – and if 36% of those cases are made incorrectly, then we’re theoretically admitting 100,000 patients for extensive and expensive evaluation.

So, are they right?  Well, if the three neurologists responsible for 93% of their 427 evaluations are representative of the entire country, perhaps.  Or, if their chart review methods are adequate – as the authors note, one of their chart audits changed an abstracted diagnosis of TIA to “right hip pain” – then, perhaps.  If you ignore that ED physicians have a few minutes of history, examination, and limited imaging available at their disposal – compared with the neurologists that can subsequently perform any manner of inpatient studies that might uncover an alternative diagnosis mimicking a TIA – then, perhaps.

If neurologists are walking into the ED and evaluating patients under the same constraints as we are and producing this level of discordance, then we have a problem.  But, I don’t think this study tells us anything we can use to evaluate ED physicians’ ability to appropriately include or exclude TIA in the differential for neurologic complaints of a transient nature.

Somewhat disappointing that a small, retrospective chart review with results that might not be internally or externally valid are in the premier, #1 Impact Factor journal of our profession.

“Variables Associated With Discordance Between Emergency Physician and Neurologist Diagnoses of Transient Ischemic Attacks in the Emergency Department”
http://www.ncbi.nlm.nih.gov/pubmed/21624703

Another recent Journal Watch article about TPA – relaying the manufacturer-sponsored message that TPA can, in fact, be given to the patients who were excluded from ECASS III because of diabetes or prior stroke.

Papers like this are fabulous.  I am 100% in agreement with the physiologic premise that timely reperfusion of the ischemic penumbra is beneficial in acute stroke.  I am less enthusiastic about using systemic thrombolysis, because it’s akin to smashing a teacup with a sledgehammer.  But, until PCI-like therapy is available/safe for the brain, it’s all we have.

I am really tired of endless papers from the TPA literature with authors falling all over themselves to present fundamentally flawed data as definitive evidence.  In this paper, the authors take the non-randomized TPA population from the SITS-ISTR – and compare it to the non-randomized, non-thrombolyzed population from the VISTA registry.  Why is this a problem?  Because even though the relative differences are large, the absolute differences are small – and we’ve already see that what makes the largest absolute difference is stroke after-care, and that all stroke centers are not created equal.  The authors acknowledge this, but then justify their results by stating that their numbers are similar to prior, retrospective, non-randomized comparisons performed on subsets of registry data.  It’s a self-fulfilling prophecy.

They conclude with “Hence, we find no justification to exclude patients from receiving alteplase for acute ischemic stroke if they have a [prior stroke] and also have [diabetes mellitus]” – which is true, unless it bothers you that the mRS 6 (dead) group nearly doubles when TPA is given to the stroke/diabetes groups.  Imagine what the reaction to ECASS III would be if TPA wasn’t 52% good outcome vs 6.7% death – and was one of these 29% good outcome vs. 23% death, or 25% good outcome vs. 28% death comparisons from the registry data (totally different baseline severity vs. ECASS III, just throwing the numbers out there for hyperbole).

…and, the obligatory: