Since 2015, when multiple international trials were reported showing clear benefit for mechanical thrombectomy in patients with large vessel occlusions, this treatment has been the standard of care. However, the speed of treatment remains paramount for good outcomes, and different models have been developed around the world in different geographic settings.
Ticagrelor is an antiplatelet agent that works by reversibly binding to P2Y12 adenosine diphosphate receptors on platelets, similar to the mechanism of action of clopidogrel. However, it is a direct-acting drug, and not a pro-drug, and does not need to be enzymatically converted to be active, like clopidogrel.
Since the pivotal trials demonstrating the benefit of endarterectomy vs. medical therapy many years ago, there has been significant improvement in the risk factors for atherosclerosis, including better treatment of blood pressure and diabetes, as well as improved antiplatelet medication regimens and high-potency statins.
Strokes, especially posterior circulation events, are associated with significant diagnostic error in the ED. Machine learning models can be designed to capture subtle signs and assist providers in catching cases that might otherwise go undetected.
Stroke prevention is complex because of the varied stroke etiologies and the multifactorial approach necessary for optimal stroke prevention and risk factor management. Inevitably, primary care providers will be part of every aspect of stroke care and, with a thorough understanding of key aspects, can greatly assist in the management of these patients.
Findings provided some assurance EDs can address time-critical illnesses even when crowded, at least when it comes to stroke care. Additional study is needed regarding patients presenting with time-sensitive illnesses, but more vague complaints.
Twenty percent to 40% of ischemic strokes are classified as cryptogenic, meaning a specific cause cannot be identified. A subset of those have been classified by some investigators as embolic stroke of undetermined source. However, this remains a controversial category and classification.
Covert brain infarcts are detected on magnetic resonance imaging studies in the aging brain in about 10% of people at age 65 years, increasing to 25% at age 80 years. Most patients who develop dementia have a combination of multiple small infarcts, plus amyloid deposition. Prevention of covert infarcts is a strategy to mitigate the frequency and severity of late-life dementia.
Multiple randomized clinical trials have demonstrated that carotid endarterectomy is beneficial in patients who have symptomatic carotid stenosis, and currently, that is the recommendation for such patients. However, in the intervening years, advances in medical therapy, as well as significant improvement in the management of blood pressure, diabetes, diet, and exercise, have been shown to reduce stroke rate. Therefore, it is currently controversial whether carotid endarterectomy is still beneficial in asymptomatic patients with carotid artery stenosis compared to current medical management.
A randomized trial of a restrictive blood transfusion strategy vs. a more liberal strategy in patients with acute myocardial infarction and anemia showed the restrictive strategy is noninferior to the liberal strategy for preventing the primary outcome of death, reinfarction, stroke, or emergency revascularization.
