Stroke Alert: A Review of Current Clinical Stroke Literature
Outcome After Acute Basilar Artery Occlusion
Source: Greving JP, et al, on behalf of the BASICS Study Group. Predicting outcome after acute basilar artery occlusion based on admission characteristics. Neurology 2012 DOI 10.1212/WNL.0b013e31824e8f40.
Basilar artery occlusion (BAO) is a grave form of ischemic stroke that carries a high morbidity and mortality. The Basilar Artery International Cooperation Study (BASICS) is a prospective, observational, international registry of consecutive patients with BAO that was radiologically confirmed. Using a multivariate logistic regression model to predict poor outcome (mRS 4-5 or death) at 1 month, the investigators developed a predictive model that can be used at the bedside.
Six hundred nineteen patients were registered and 429 (69%) had a poor outcome at 1 month: 74 (12%) had an mRS score of 4, 115 (19%) had an mRS score of 5, and 240 (39%) died. The most important and statistically significant predictors of poor outcome, based on demographic data and stroke risk factors calculated by area under the receiver operating characteristic curve (AUC), were older age, absence of hyperlipidemia, presence of prodromal minor stroke, NIH Stroke Scale score > 20, and a longer time to treatment. With the inclusion of the neurological examination and CT imaging, the AUC reached 0.80 (0.77-0.84), indicating a high reliability for predicting outcome.
Closure of Patent Foramen Ovale after Stroke Is No Better Than Medical Therapy Alone
Source: Furlan AJ, et al, for the CLOSURE Investigators. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. New Engl J Med 2012;366:991-999.
The prevalence of patent foramen ovale (PFO) in patients diagnosed with cryptogenic stroke is higher than in the general population (20 to 26%) and has been considered a possible cause of stroke via paradoxical right-left shunting in the heart. As a result, there has been off-label use of various closure devices to treat this condition, without evidence-based information to guide clinicians. The investigators conducted a multicenter, randomized, open-label trial of closure with a percutaneous device, as compared to medical antithrombotic therapy alone, in 909 patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary endpoint was the rate of stroke or TIA during 2 years of follow-up, death during the first 30 days, or death from any cause during 2 years of follow-up. The closure group was treated with clopidogrel and aspirin after the procedure, and the medical group was treated with aspirin, warfarin, or both, during the 2-year follow-up period.
The cumulative incidence of stroke or TIA was 5.5% in the closure group compared to 6.8% in the medical therapy group (HR = 0.78; 95% confidence interval [CI], 0.45 to 1.35; P = 0.37). No deaths occurred in either group and there were no procedural complications. In the recurrent ischemic events, a cause other than paradoxical embolism was usually found. In patients with cryptogenic stroke or TIA who had a PFO, closure was not statistically better than medical therapy in preventing recurrent ischemic events. However, there may be a subgroup of young patients who do benefit, but a trial to determine this would require an enrollment size that is not feasible. In addition, the optimal medical therapy for patients with stroke and a PFO is also not clear from this study's data.
Tenecteplase: A New and Promising Agent for Intravenous Thrombolysis
Source: Parsons M, et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med 2012;366:1099-1107.
Intravenous alteplase (RTPA) is the only approved therapy for acute ischemic stroke, and it has limited benefit. Tenecteplase, a more potent thrombolytic agent that is a genetically engineered plasminogen activator, was tested as an alternative agent in a randomized, three-arm trial comparing two doses of tenecteplase (0.1 mg/kg or 0.25 mg/kg) with the approved dose of rTPA (0.9 mg/kg). Seventy-five patients with acute ischemic stroke who had CT perfusion evidence for at least a 20% perfusion/infarct mismatch by CT perfusion study, and an associated vessel occlusion on CT angiography, were randomly assigned to one of three treatment groups within 6 hours of symptom onset. The primary endpoints were the proportion of the perfusion lesion that was reperfused at 24 hours, and the extent of clinical improvement at 24 hours as assessed by the NIH Stroke Scale.
Each group had 25 patients and the mean time to treatment was 2.9 ± 0.8 hours. Analyzed together, both tenecteplase groups had greater reperfusion (P = 0.004) and clinical improvement (P < 0.001) at 24 hours than the alteplase group, and there were no differences in adverse events (death or intracranial bleeding) between the groups. The higher dose of tenecteplase was superior in all outcomes, to the lower dose of tenecteplase and to alteplase, including absence of serious disability at 3 months. Tenecteplase, administered intravenously, was associated with better reperfusion and clinical outcomes than alteplase, and should be tested in a definitive Phase 3 trial.Basilar artery occlusion (BAO) is a grave form of ischemic stroke that carries a high morbidity and mortality. The Basilar Artery International Cooperation Study (BASICS) is a prospective, observational, international registry of consecutive patients with BAO that was radiologically confirmed.
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