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C2 > Treatment of ischaemic/haemorrhagic stroke > Flashcards

Treatment of ischaemic/haemorrhagic stroke Flashcards

1
Q

what types of hyperacute treatments are there

A

iv thrombolysis

mechanical thrombectomy

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2
Q

what trials show iv thrombolysis

A

NINDS trial 1996
Cochrane review
ECASS-3
IST-3

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3
Q

what happened in the NINDS-2 trial?

A

tPA or placebo given within 3 hours

favourable outcome at 3 months - 4 statistic including mRankin scale

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4
Q

what happened in the Cochrane review 2003

A 
18 trials, 5727 patients
4 agents: rtPA (50%), SK, UK, rpUK
fewer patients dead or dependent 
more deaths in first 7-10 days
rtPA possibly less hazard and more benefit
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5
Q

what happened in ECASS-3: 3-4half hours?

A

european trial

MINDS trial repeated with same inclusion/exclusion criteria but different time window

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6
Q

what happened in IST-3

A

biggest trial of intravenous throm
ran for many years
looked at group of patients not eligible for standard thrombolysis. a study of the patients who could not be thrombolysed routinely older patients >80

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7
Q

what happened in the wake-up trial

A

2018 sweden trial
patients with unknown time of onset
last known well > 4.5hr ago
stroke < 4.5 hr ago

within minutes of stroke happening, infarction on brain shows up very bright on dwi
flair signal takes about 4.5 hrs to develop
results: 503 patients, favourable outcome in 53.3%

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8
Q

what happened in the EXTEND trial

A

4.5 to 9hr after stroke onset or woke within 9hr of midpoint of sleep
Perfusion mismatch - CT or MR perfusion. 225 of planned 310 patients enrolled. stopped early

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9
Q

how is IV tPA given now

A

within 4.5 hrs, rapid plain CT
see if safe to give thromolysis
ct/mr perfusion to look for mis match and how much brain to save.
known onset beyond 4.5-9 hrs - small sub-group who may still benefit

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10
Q

what happened in IMS-3 trial

A

in 2013. IV tPA and endovascular vs only IV tPA as treatment.
IV tPA given within 3 hours of stroke onset
trial was stopped

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11
Q

negative trials

A

IMS-33, synthesis-expansion, MR-RESCUE

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12
Q

new devices for treatment

A

penumbra

solitaire

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13
Q

what happened in MR CLEAN trial

A

in 2015. Dutch study.
500 patients in 16 centres. assessed intra-arterial vs standard care. MT or ia tPD
carotid-T, M1, M2, A1, A2 occlusion
89% had iv tPA before randomisation

there was a long time window between tPA given and when randomised

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14
Q

what happened in ESCAPE 2015 trial

A

stopped for efficacy

analysis at 300 but planned sample size 500 but unplanned interim analysis at 315 because of MR CLEAN

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15
Q

ESCAPE protocol

A 
good pre-morbid state
enrollment up to 12hr post-stroke
CT and CTA (multiphase preferred)
small core infarct
M1 or M2 occlusion 
moderate to good collaterals on CTA
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16
Q

what happened in EXTEND-IA 2015

A 
tPA candidates only (4.5 hr window)
M1/M2 occlusions
endovascular within 6 hr
CT perfusion for salvageable tissue
planned for 100 patients but stopped for efficacy after 70 patients. unplanned analysis after MR CLEAN
17
Q

what happened in SWIFT-PRIME 2015

A

initially using CT perfusion

changed to using ASPECTS > 7

18
Q

what happened in REVASCAT 2015

A

206 patients from Catalonia

ASPECTS > 7

19
Q

Name 2 studies in 2016

A

THRACE 2016

PISTE 2016

20
Q

what happened in DAWN

A

206 patients
pre stroke mRS 0-1
terminal ICA, or M1 occlusion
9% given tPA
infarct volume on DWI or CTP
assess penumbra by looking at patient see how much brain threatened by infarction
use imaging to establish core patient with big stroke but small core
showed 73% relative risk reduction of dependency in ADLs NNT for any lower disability 2.0

21
Q

what happened in DEFUSE-3

A 
pre-stroke mRS 0-2
NIHSS > 6 at randomisation
6-16 hrs from onset
not given iv tPA
terminal ICA or M1 occlusion
core < 70ml
penumbra > 15 ml
total ischaemic vol > 1.8
22
Q

other ways to try treatment

A

tenecteplase (modified from tPA) given as single injection –> 3 trials: ATTEST-2, TWIST, TEMPO-2
therapeutic cooling
spinning iron microbeads

23
Q

what happened in Vahedi et al 2007

A

clincally MCA infarct of NIHSS

CT infarct > 50% of MCA territory

24
Q

what happened in interact 2

A

primary ICH and sBP 150-220
not comatose
intensive BP lowering vs standard

25
Q

what happened in TICH-2

A

patients with primary ICH
tranexamic acid vs placebo
treatment within 8 hrs of onset
dead or dependent at 90 days

C2 (24 decks)

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