Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Professor and Chairman, Department of Neurology, Weill Cornell Medical College, and Neurologist-in-Chief, New York Presbyterian Hospital
Prehospital Triage to Primary Stroke Centers Improves Treatment
Source: Prabhakaran S, et al. Prehospital triage to primary stroke centers and rate of stroke thrombolysis. JAMA Neurol 2013;70:1126-1132. doi:10.1001/jamaneurol.2013.293.
The city of chicago, IL, has 2.85 million residents who are ethnically diverse, and a single 911 emergency care provider system, the fire department, that takes all suspected stroke victims to the local hospitals. In 2009, the state of Illinois legislated that all suspected stroke patients be triaged to a designated primary stroke center certified by the Joint Commission, and the authors of this paper evaluated the impact of this policy in a multicenter cohort study that began in September 1, 2010 to August 31, 2011. Data were collected using the American Heart Association Get-With-The-Guidelines database and the main outcome measured was the fraction of patients with ischemic strokes who received intravenous tPA.
There were 1075 stroke and TIA patients admitted in the pretriage 6-month period, and 1172 patients in the post-triage period. Demographic characteristics (age, sex, risk factors) were similar for the two groups (mean age = 65 years; 53% female). Compared with the pretriage period, EMS services increased from 30.2% to 38.1%, and prenotification increased from 65.5% to 76.5%, after implementation of the new policy. Rates of intravenous tPA use were 3.8% before triage and 10.1% after triage (P < 0.001), and onset-to-treatment times decreased from 171.7 minutes to 145.7 minutes (P < 0.03). Symptomatic intracranial hemorrhage and in-hospital mortality were not significantly different between the two periods. Implementation of a triage policy for stroke patients, directing them to a specialized stroke center, was independently associated with increased tPA use for patients with ischemic stroke.
More Good News About the Mediterranean Diet!
Source: Psaltopoulou T, et al. Mediterranean diet, stroke, cognitive impairment, and depression: A meta-analysis. Ann Neurol 2013; online DOI: 10.1002/ana.23944.
In a comprehensive meta-analysis, the authors reviewed all published studies that looked at the association of adherence to the Mediterranean diet and the risk of stroke, depression, cognitive impairment, and Parkinson’s disease. Studies were included if they provided a relative risk estimate for the use of the Mediterranean diet and the above outcomes, and further analysis was performed to assess the effects of high and moderate adherence. Twenty-two eligible studies were included (11 covered stroke, 9 depression, 8 cognitive impairment, and 1 Parkinson’s disease). High adherence to the Mediterranean diet was associated with reduced risk for stroke (relative risk [RR], 0.71; 95% confidence interval [CI], 0.43-0.83), depression (RR, 0.68; 95% CI, 0.54-0.86), and cognitive impairment (RR, 0.60; 95% CI, 0.43-0.84). Moderate adherence was also associated with reduced risk for depression and cognitive impairment; the effects on stroke were marginal. Regression analysis indicated that the effects on stroke of the Mediterranean diet were more robust among men compared to women. The effects of the diet on depression seemed independent of age. Data were inadequate to make any statements regarding the effects of the Mediterranean diet on Parkinson’s disease. On balance, the diet had many favorable effects on the major diseases of the aging brain.
Combined Intravenous Therapy with tPA and Eptifibatide is Reported as Safe
Source: Pancioloi AM, et al. for the CLEAR-ER investigators. Combined Approach to Lysis Utilizing Eptifibitide and Recombinant Tissue Plasminogen Aactivator in Acute Ischemic Stroke Enhanced Regimen Stroke Trial. Stroke 2013;44:2381-2387.
At the present time, there is no other treatment for acute ischemic stroke that has been proven safe and effective, other than intravenous tPA. Yet this therapy has many shortcomings, and intra-arterial therapy is still being developed and not yet proven to be more effective than intravenous tPA. In addition, activation of the endovascular team, in the best of hands, still takes hours, and it is likely that these delays are unavoidable. So the search continues for more effective intravenous therapy that can be administered quickly in the emergency department. The combination of intravenous tPA with a GPIb/IIIa inhibitor has been an attractive combination and was tested successfully in the CLEAR-ER trial, reported this month in Stroke. The investigators used a dose of IVtPA of 0.6 mg/kg followed by IV eptifibitide (bolus 135 mcg/kg and a 2-hour infusion at 0.75 mcg/kg per minute) compared to standard dose IVtPA (0.9 mg/kg). The randomization was 5:1, with the majority given combined therapy. Of 126 total subjects, 101 received combined therapy and 25 received standard dose IVtPA. Two patients (2%) in the combination group and three (12%) in the standard group had symptomatic intracranial hemorrhage. At 90 days, 49.5% of the combination group had a modified Rankin score of ≤ 1 or return to baseline, compared to 36% in the standard group (NS).
The study was powered and designed to determine safety, and the investigators proved their primary hypothesis that combination therapy is safe. It still remains to be determined if this combination therapy with be more effective than IVtPA alone, and this will require a phase 2-3 trial with 1:1 randomization.