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

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RAIN 2019: Ischemic Stroke

Wade S. Smith, MD, PhD

Chief, UCSF Neurovascular Division Professor, UCSF Department of Neurology

Disclosures

• NIH
• U24 NS 107229 (PI) NorCal RCC
• Consultant:
• DSMB: Stryker Inc.

Wade S. Smith, MD, PhD

Chief, UCSF Neurovascular Division Professor, UCSF Department of Neurology

Nogueira et al, NEJM 378: 11-21,2018

DAWN Trial

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Albers, et al, Epub NEJM January 24, 2018

DEFUSE-3 Trial

Outcomes by Time

27 13 17 46 49 45 10 20 30 40 50 60 HERMES DAWN DEFUSE-3 Control Thrombectomy

IV t-PA effect? Ischemic Creep?

2018 UCSF Acute Stroke Protocol

Major Conclusions

• Embolectomy with stent retrievers improve clinical
• utcome 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

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DWI + FLAIR – WAKE-UP strokes

LKW

NEJM 2018;379(7): 611

Good Outcome (OR 1.61 95% CI, 1.09-2.36, p=0.02) ICH rate 2.0% vs. 0.4%, P=0.15

JAMA 2018;320(2):156 No difference ICH rate 3.2% vs. 0, NS

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Tenecteplase

• Single bolus
• Non-inferior c/w t-PA by meta analysis

(Burgos et al)

• TIMELESS Trial: > 4.5 – 9 hours,

perfusion selected, tnk + placebo f/b EVT

Need for Perfusion Imaging?

• Large core infarcts do better with EVT c/w

MM: ASPECTS < 5, core infarct > 50 cc (Sarraj A et al) 32% vs. 14%

• DAWN criteria vs. clinical- ASPECTs

mismatch- performed similarly (Bouslama et al)

• Beyond CTA is there a need for perfusion?

t-PA 4.5-9 hours

• Ma et al
• 113 IV t-PA vs. 112 placebo, 4.5-9 hours,

perfusion selected

• 35 v 29% mRS 0-1 (p=0.042)
• ICH 6% vs. 1 %

BP control

• No change in outcome if BP lowered

following EVT

• ENCHANTED: lowering vs. not BP

following IV-T-PA: no change in outcome (Anderson et al)

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Systems of Care

• 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 Thank You