RAIN 2019: Ischemic Stroke Disclosures NIH U24 NS 107229 (PI) - PowerPoint PPT Presentation

RAIN 2019: Ischemic Stroke Disclosures •NIH •U24 NS 107229 (PI) NorCal RCC •Consultant: • DSMB: Stryker Inc. Wade S. Smith, MD, PhD Wade S. Smith, MD, PhD Chief, UCSF Neurovascular Division Chief, UCSF Neurovascular Division Professor, UCSF Department of Neurology Professor, UCSF Department of Neurology DAWN Trial Nogueira et al, NEJM 378: 11-21,2018 1

DEFUSE-3 Trial Outcomes by Time IV t-PA effect? 60 Ischemic Creep? 49 50 46 45 40 30 27 20 17 13 10 0 HERMES DAWN DEFUSE-3 Control Thrombectomy Albers, et al, Epub NEJM January 24, 2018 Major Conclusions 2018 UCSF Acute Stroke Protocol • Embolectomy with stent retrievers improve clinical outcome if done with 24 hours of symptom onset for anterior circulation ischemia • Earlier treatment improves outcome if onset < 6 hours • Thrombectomy is safe and effective from 6-24 hours provided they have favorable perfusion • You should be performing CTA in all patients seen within 24 hours of ischemic stroke onset 2

DWI + FLAIR – WAKE-UP strokes LKW Good Outcome (OR 1.61 95% CI, 1.09-2.36, p=0.02) ICH rate 2.0% vs. 0.4%, P=0.15 NEJM 2018;379(7): 611 JAMA 2018;320(2):156 No difference ICH rate 3.2% vs. 0, NS 3

Tenecteplase Need for Perfusion Imaging? • Single bolus • Large core infarcts do better with EVT c/w MM: ASPECTS < 5, core infarct > 50 cc • Non-inferior c/w t-PA by meta analysis (Sarraj A et al ) 32% vs. 14% (Burgos et al) • DAWN criteria vs. clinical- ASPECTs • TIMELESS Trial: > 4.5 – 9 hours, mismatch- performed similarly (Bouslama perfusion selected, tnk + placebo f/b EVT et al) • Beyond CTA is there a need for perfusion? t-PA 4.5-9 hours BP control • Ma et al • No change in outcome if BP lowered following EVT • 113 IV t-PA vs. 112 placebo, 4.5-9 hours, perfusion selected • ENCHANTED: lowering vs. not BP following IV-T-PA: no change in outcome • 35 v 29% mRS 0-1 (p=0.042) (Anderson et al) • ICH 6% vs. 1 % 4

Systems of Care Thank You • Outcomes at CSCs with higher volume are better • Robinson et al : 49% sensitivity by paramedics in identifying stroke • Experience with direct to cath lab referrals • Lack of good method for prehospital dx • CTA in ambulance, teleneurology • Biometrics University of California, San Francisco 5