Is Direct Endovascular Treatment as an Alternative of Bridging Therapy in Acute Stroke Patients with Large Vessel Occlusion?

2019 ◽  
Vol 28 (3) ◽  
pp. 531-541
Author(s):  
Mingsu Liu ◽  
Guangqin Li
2020 ◽  
pp. 174749302092534
Author(s):  
Zhongming Qiu ◽  
Hansheng Liu ◽  
Fengli Li ◽  
Weidong Luo ◽  
Deping Wu ◽  
...  

Background Eight randomized controlled trials have consistently shown that endovascular treatment plus best medical treatment improves outcome after acute anterior proximal intracranial large vessel occlusion strokes. Whether intravenous thrombolysis prior to endovascular treatment in patients with anterior circulation, large vessel occlusion is of any additional benefits remains unclear. Objective This study compares the safety and efficacy of direct endovascular treatment versus intravenous recombinant tissue-type plasminogen activator bridging with endovascular treatment (bridging therapy) in acute stroke patients with intracranial internal carotid artery or middle cerebral artery-M1 occlusion within 4.5 h of symptom onset. Methods and design The DEVT study is a randomized, controlled, multicenter trial with blinded outcome assessment. This trial uses a five-look group-sequential non-inferiority design. Up to 194 patients in each interim analysis will be consecutively randomized to direct endovascular treatment or bridging therapy group in 1:1 ratio over three years from about 30 hospitals in China. Outcomes The primary end-point is the proportion of independent neurological function defined as modified Rankin scale score of 0 to 2 at 90 days. The primary safety measure is symptomatic intracerebral hemorrhage at 48 h and mortality at 90 days. Trial registry number ChiCTR-IOR-17013568 ( www.chictr.org.cn ).


2019 ◽  
Vol 14 (7) ◽  
pp. 734-744 ◽  
Author(s):  
Sònia Abilleira ◽  
Natalia Pérez de la Ossa ◽  
Xavier Jiménez ◽  
Pere Cardona ◽  
Dolores Cocho ◽  
...  

Rationale Optimal pre-hospital delivery pathways for acute stroke patients suspected to harbor a large vessel occlusion have not been assessed in randomized trials. Aim To establish whether stroke subjects with rapid arterial occlusion evaluation scale based suspicion of large vessel occlusion evaluated by emergency medical services in the field have higher rates of favorable outcome when transferred directly to an endovascular center (endovascular treatment stroke center), as compared to the standard transfer to the closest local stroke center (local-SC). Design Multicenter, superiority, cluster randomized within a cohort trial with blinded endpoint assessment. Procedure Eligible patients must be 18 or older, have acute stroke symptoms and not have an immediate life threatening condition requiring emergent medical intervention. They must be suspected to have intracranial large vessel occlusion based on a pre-hospital rapid arterial occlusion evaluation scale of ≥5, be located in geographical areas where the default health authority assigned referral stroke center is a non-thrombectomy capable hospital, and estimated arrival at a thrombectomy capable stroke hospital in less than 7 h from time last seen well. Cluster randomization is performed according to a pre-established temporal sequence (temporal cluster design) with three strata: day/night, distance to the endovascular treatment stroke center, and week/week-end day. Study outcome The primary endpoint is the modified Rankin Scale score at 90 days. The primary safety outcome is mortality at 90 days. Analysis The primary endpoint based on the modified intention-to-treat population is the distribution of modified Rankin Scale scores at 90 days analyzed under a sequential triangular design. The maximum sample size is 1754 patients, with two planned interim analyses when 701 (40%) and 1227 patients have completed follow-up. Hypothesized common odds ratio is 1.35.


Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Qing Hao ◽  
Jacob Morey ◽  
Xiangnan Zhang ◽  
Emily Chapman ◽  
Reade DeLeacy ◽  
...  

2019 ◽  
Vol 90 (e7) ◽  
pp. A39.1-A39
Author(s):  
Jonathan JD Baird-Gunning ◽  
Shaun Zhai ◽  
Brett Jones ◽  
Neha Nandal ◽  
Chandi Das ◽  
...  

Introduction25%-30% of patients admitted with acute stroke are stroke mimics. Clinical assessment plays a major role in diagnosis in the hyperacute clinical setting. Identifying physical signs that correctly identify stroke is therefore important. A retrospective study1 suggested that the presence of sensory inattention (or neglect) was seen exclusively in stroke patients, suggesting that inattention might be a reliable discriminator between stroke and mimics. This study aimed to test that hypothesis.MethodsProspective assessment of suspected stroke patients for the presence of neglect (NIHSS definition). Neglect could be visual and/or somatosensory. The presence of neglect was then correlated with eventual diagnosis at 48 hours. Sensitivity, specificity and predictive values were calculated. A post-hoc analysis evaluated the correlation of neglect with large vessel occlusion in patients who underwent angiography.Results115 patients were recruited, 70 ultimately with stroke and 45 with other diagnoses. Neglect was present in 27 patients (of whom 23 had stroke) and absent in 88. This yielded: sensitivity 32.9%, specificity 91.1%, positive predictive value 85.2%, and negative predictive value 41.9%. Two patients with neglect had a diagnosis of functional illness, one a seizure, and one a brain tumour. Neglect was present in 7 out of 8 patients with large vessel occlusion (sensitivity 87.5%) and was absent in all patients who did not have large vessel occlusion on angiogram.ConclusionWhen present, neglect is a strong predictor of organic pathology and large vessel occlusion. However, it is not 100% specific and can be seen in functional presentations.ReferenceGargalas S, Weeks R, Khan-Bourne N, Shotbolt P, Simblett S, Ashraf L, Doyle C, Bancroft V, David AS: Incidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit. J Neurol Neurosurg Psychiatry 2017, 88:2–6.


Stroke ◽  
2019 ◽  
Vol 50 (1) ◽  
pp. 212-217 ◽  
Author(s):  
Jessalyn K. Holodinsky ◽  
Mohammed A. Almekhlafi ◽  
Mayank Goyal ◽  
Noreen Kamal

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