Emergency Medicine Literature of Note
Musings on Emergency Medicine, Clinical Informatics, & High-Value Care.
The verdict is in: “Aspiration Thrombectomy No Help for Large-Clot Strokes”, reports MedPage Today. Except, they’re not precisely correct – in a way, you could even say they’re wrong. This is THERAPY, an endovascular trial in acute stroke featuring the Penumbra aspiration device. This is somewhat unique, as the technology differs from the otherwise popularized … Continue reading “Don’t Stop at the Headline”
This is TRAPID-AMI, a prospective Roche hs-TnT (99th percentile 14ng/L) study for patients presenting within 6 hours of peak chest pain symptoms. Samples were drawn on arrival, then serially over the next two hours, and a final sample drawn 4-14h after presentation. The primary outcome was acute MI, as adjudicated by a panel of cardiologists … Continue reading “Zeno’s Zero-Hour Rule-Outs”
Endovascular intervention for acute stroke can be quite useful – in appropriately selected patients. However, few centers are capable of such interventions, and the technology to properly angiographically evaluated for large-artery occlusions is not available in all settings. Thus, it is just as critical for patients to be clinically screened in some fashion to prevent … Continue reading “Triaging Large Artery Occlusions”
It’s easy to fall prey to the quality assurance shaming associated with your hospital’s stroke team. It’s nearly impossible to find the right balance between over-triage of any remotely neurologic complaint, and getting the inevitable nastygram follow-ups resulting from unexpected downstream stroke diagnoses. Take heart: it’s not just you. This retrospective review of evaluated patients … Continue reading “Missed a Stroke? You’re Not Alone”
The new AHA guidelines for the use of endovascular therapy in acute ischemic stroke broadly include any patient within six hours of symptom onset. These criteria are based, mostly, on MR-CLEAN – in spite of the follow-up EXTEND-IA, ESCAPE, and SWIFT-PRIME showing the highest yield patients are clearly those with salvageable tissue. Treatment beyond six … Continue reading “Tissue, Not Time, for Stroke”
It seems to be the stroke neurologists’ greatest lament – the restricted time windows for tPA, either 3 or 4.5 hours, excluding so many patients from receiving the blessing of thrombolysis. There have been failed trials in the past in extended time windows, and, even, failed trials in the 3-5h time window. But, this is … Continue reading “DIAS-3 – Desmoteplase Fails in the Extended Time Window”
The year 2012 was dark times for endovascular treatment for acute ischemic stroke. MR-RESCUE, IMS-3, and SYNTHESIS were all decidedly negative, and their failures trotted out in the New England Journal of Medicine. This current year has been much better – a trove of trials following the initial positive result of MR-CLEAN, the key features … Continue reading “Back to IMS-III: It’s the Collaterals”
The conceptual mainstay of interventions for acute ischemic stroke is recanalization. The “clot buster” – tPA. The “clot retriever” – the endovascular stent devices. These are interventions aimed at opening an occluded vessel and restoring flow. But, as it turns out, recanalization is only part of the story. The other half – and the not … Continue reading “Muddying Acute Stroke With Recanalization vs. Reperfusion”
Over 200,000 physicians belong to the American Medical Association. The Journal, therefore, of this Association has a significant audience and a long tradition. Continuing Medical Education inserts in JAMA may represent the basic education of many new developments for general practitioners. Unfortunately, the authors of this most recent CME portion seem to require their own … Continue reading “A Laughable tPA “Systematic Review””
Discovery Channel had Shark Week. Around Emergency Literature of Note Headquarters, we do Stroke Week. Why? Because, from a methodologic standpoint, acute stroke care is the gift that keeps on giving. This week, we will see randomized-controlled trials stopped for “loss of equipoise”, a few authors who are still working out how to conduct a … Continue reading “It’s Stroke Week Again!”