STROKE CARE UPDATES GRAND ROUNDS – Dr. Jagoda
QUESTION 1: Do the benefits of TPA outweigh the risks of symptomatic ICH (sICH)?
NNT for TPA <3hrs is 1:3 for a benefit (MRS improved 1 pt)
- Critics dismiss 1-point move as sig outcome, but it is a large QOL change.
NNT for TPA within 4.5 hrs is 1:6
Best outcomes are within 90min. Mortality increases after 4.5 hours.
- Significant benefit (i.e. MRS 0/1 from 26 -36 %, OR 1.7) but hemorrhage rate 0.6 vs 6.4% in TPA group
Data re-analysis – 2004
- Still found data for benefit
Clarified RF for bleeding risk (0 RF risk 1.8%, 1 RF is 4.9%, >1 RF risk is 21%)
- sICH RF: NIHSS >20, Age >70, Ischemic changes on CT, Glucose >300
- Can/should use THRIVE score to estimate bleeding risk (on MDcalc)
SITS-MOST Study: Validated practical application of rt-TPA in community setting with improved outcomes. 4.6% sICH.
ECASS-3 expanded TPA window to 4.5 hours w/ a dichotomous variable of MRS 0/1 or 2+. Increased ICH risk, but benefit is preserved.
- 52% vs 45% w/ MRS 0/1 (CI low end is 1.02 for OR)
- sICH 2.4% vs 0.2. No mortality difference. All ICH was 27% vs 17%.
GWTG Stroke program analysis
- Validated 90 minute cut-off associated w/ decrease mortality vs 90-180
- sICH 4-5%
Sinai sICH rate around 4% overall, but we need to be giving patients more individualized sICH risks than 6.8% for everyone.
Updated exclusion criteria includes more folks (see last two pages for summary).
- Example: Glucose >400 removed, glucose <50 not contra if sx persist post correction
QUESTION 2: Does neurothrombectomy offer benefit? Yes
Initial studies with Mercy device did not demonstrate benefit
Newer devices (Solitaire, Stentreiver) with much better outcomes: NNT 2.6
DAWN Trial just published in NEJM, Nogueira et al
- Thrombectomy 6-24hrs (ie out of TPA window) for occlusion of ICA or MCA
- Functional indep 49% vs 13% std of care (NNT 2.8 for functional indep)
- sICH 6% vs 3% w/ no mortality diff