Emergency Medicine Literature of Note
Musings on Emergency Medicine, Clinical Informatics, & High-Value Care.
It had been a few weeks since I perused the recently published articles in Stroke – and there were so many: 1) not quite enough for their own angry post, but 2) worth noting, so, here we are: Emergency Department Door-to-Puncture Time Since 2014: Observations From the BEST-MSU Study https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.025106 This one comes with the … Continue reading “Wednesday is for Stroke”
Did you miss the publication of EXTEND a couple weeks ago – a publication I helpfully labeled as “shenanigans“? Well, these same authors have wasted little time performing a systematic review and meta-analysis of individual patient data in the 4.5-9 hour timeframe. Their search, specifically limited to hemispheric stroke and pretreatment perfusion/diffusion evaluation, identifies: EXTEND, ECASS4-EXTEND, … Continue reading “The EXTEND Alteplase Meta-Analysis”
Do you remember EXTEND-IA? Or EXTEND-IA TNK? This is, well, their neglected little brother, regular old EXTEND, stumbling along to “completion” and publication in the New England Journal of Medicine, as is apparently their birthright. EXTEND-IA was part of the enormously important series of trials launching the endovascular revolution for acute ischemic stroke. EXTEND-IA TNK … Continue reading “EXTEND Alteplase Shenanigans!”
What happens when you wake up and you’re paralyzed from a stroke? Well, usually nothing. “Unknown time of onset” takes you – for better or worse – out of the game for alteplase, but not necessarily for endovascular therapy should a large-vessel occlusion be identified. Those large vessel occlusions, in the setting of a favorable … Continue reading “Wake Up and Smell the tPA”
This article is mostly a story about tenecteplase, but, effectively, it’s also a scathing indictment of alteplase – you know, the miraculous “clot-buster” we’ve been using for the past 23 years. Because, despite rumors to the contrary, it doesn’t actually bust clots. This isn’t news to anyone who actually follows the stroke literature closely. Indeed, … Continue reading “The Futility of Alteplase”
This article is conceptually quite strange – and that’s evident right in the title. Time from imaging, not time from onset, is the determining factor in outcomes from acute stroke? However, despite the overall oddity of their premise, there’s at least one pearl demonstrated here: patients with excellent collateral circulation are far more resilient. This … Continue reading “More “Time Is (Not) Brain” Nuances”
So, DAWN and DEFUSE-3 show it is reasonable to use tissue-based criteria to guide intervention, rather than the quaint, but anachronistic, concept of “time is brain.” However, in expanding this window, what is the yield of screening? How many CT cerebral angiograms with specialized perfusion imaging will need to be performed to identify a patient … Continue reading “How Many 6-to-24 Hour Stroke Patients Are Eligible?”
A couple months ago the stroke community was presented with the results of DAWN – an acute stroke trial leaving us longing wistfully of the simple days where we just bickered over tPA in the 3-hour window. With DAWN, the authors evaluated patients with symptoms of 6 to 24 hour duration and found, with specific … Continue reading “DEFUSE-3 is DAWN All Over Again”
It wasn’t truly so long ago the treatment for an acute stroke was virtually nonexistent. Then, it progressed, with patients eligible for treatment within 3 hours … then 4.5 hours … then 6 … and, now, 24 hours. Whatever happened to “time is brain”? How can we possibly be treating patients out to a day … Continue reading ““DAWN” of the Mismatch Era”
It’s the thing to do in stroke – wedge new treatments into practice with a narrow time window and strict eligibility requirements, then expand, expand, expand. This latest publication/advertising supplement in the Journal of the American Medical Association pools together the endovascular trials MR CLEAN, ESCAPE, EXTEND-IA, REVASCAT, and SWIFT-PRIME for an individual-patient meta-analysis to … Continue reading “Stretch That Thrombectomy Window”