scholarly journals 2019 Update of the Korean Clinical Practice Guidelines of Stroke for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

2020 ◽  
Vol 38 (2) ◽  
pp. 77-87 ◽  
Author(s):  
Sang-Bae Ko ◽  
Hong-Kyun Park ◽  
Byung Moon Kim ◽  
Ji Hoe Heo ◽  
Joung-Ho Rha ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Acute Ischemic Stroke ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Randomized Clinical Trials ◽  
Time Window ◽  
Late Time ◽  
Large Artery ◽  
Endovascular Recanalization

Endovascular recanalization therapy (ERT) has been a standard of care for patients with acute ischemic stroke due to large artery occlusion (LAO) within 6 hours after onset since the five landmark ERT trials up to 2015 demonstrated its clinical benefit. Recently, two randomized clinical trials demonstrated that ERT, even in the late time window up to 16 hours or 24 hours after last known normal time, improved the outcome of patients who had a target mismatch defined as either clinical-core mismatch or perfusion-core mismatch, which prompted the update of national guidelines in several countries. Accordingly, to provide evidence-based and up-to-date recommendations for ERT in patients with acute LAO in Korea, the Clinical Practice Guidelines Committee of the Korean Stroke Society decided to revise the previous Korean Clinical Practice Guidelines of Stroke for ERT. For this update, the members of the writing group were appointed by the Korean Stroke Society and the Korean Society of Interventional Neuroradiology. After thorough reviewing the updated evidence from two recent trials and relevant literature, the writing members revised recommendations, for which formal consensus was achieved by convening an expert panel composed of 45 experts from the participating academic societies. The current guidelines are intended to help healthcare providers, patients, and their caregivers make their well-informed decisions and to improve the quality of care regarding ERT. The ultimate decision for ERT in a particular patient must be made in light of circumstances specific to that patient.

scholarly journals Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

2016 ◽  
Vol 18 (1) ◽  
pp. 102-113 ◽  
Author(s):  
Keun-Sik Hong ◽  
Sang-Bae Ko ◽  
Kyung-Ho Yu ◽  
Cheolkyu Jung ◽  
Sukh Que Park ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Acute Ischemic Stroke ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Endovascular Recanalization

scholarly journals Etiologic Workup in Cases of Cryptogenic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1419-1427 ◽  
Author(s):  
Naoimh E. McMahon ◽  
Munirah Bangee ◽  
Valerio Benedetto ◽  
Emma P. Bray ◽  
Rachel F. Georgiou ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Secondary Prevention ◽  
Acute Ischemic Stroke ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Cryptogenic Stroke ◽  
Unique Identifier ◽  
Missed Opportunities ◽  
Consensus Statements

Background and Purpose— Identifying the etiology of acute ischemic stroke is essential for effective secondary prevention. However, in at least one third of ischemic strokes, existing investigative protocols fail to determine the underlying cause. Establishing etiology is complicated by variation in clinical practice, often reflecting preferences of treating clinicians and variable availability of investigative techniques. In this review, we systematically assess the extent to which there exists consensus, disagreement, and gaps in clinical practice recommendations on etiologic workup in acute ischemic stroke. Methods— We identified clinical practice guidelines/consensus statements through searches of 4 electronic databases and hand-searching of websites/reference lists. Two reviewers independently assessed reports for eligibility. We extracted data on report characteristics and recommendations relating to etiologic workup in acute ischemic stroke and in cases of cryptogenic stroke. Quality was assessed using the AGREE II tool (Appraisal of Guidelines for Research & Evaluation). Recommendations were synthesized according to a published algorithm for diagnostic evaluation in cryptogenic stroke. Results— We retrieved 16 clinical practice guidelines and 7 consensus statements addressing acute stroke management (n=12), atrial fibrillation (n=5), imaging (n=5), and secondary prevention (n=1). Five reports were of overall high quality. For all patients, guidelines recommended routine brain imaging, noninvasive vascular imaging, a 12-lead ECG, and routine blood tests/laboratory investigations. Additionally, ECG monitoring (>24 hours) was recommended for patients with suspected embolic stroke and echocardiography for patients with suspected cardiac source. Three reports recommended investigations for rarer causes of stroke. None of the reports provided guidance on the extent of investigation needed before classifying a stroke as cryptogenic. Conclusions— While consensus exists surrounding standard etiologic workup, there is little agreement on more advanced investigations for rarer causes of acute ischemic stroke. This gap in guidance, and in the underpinning evidence, demonstrates missed opportunities to better understand and protect against ongoing stroke risk. Registration— URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42019127822.

scholarly journals Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

2020 ◽  
Vol 12 (Suppl. 1) ◽  
pp. 49-55
Author(s):  
Huong Bich Thi Nguyen ◽  
Thang Huy Nguyen
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Recurrent Stroke ◽  
Reperfusion Therapy ◽  
Artery Occlusion ◽  
Large Artery ◽  
Limited Information ◽  
Anterior Circulation ◽  
Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

Abstract TP372: Outcomes of the Extended Ischemic Stroke Treatment Window

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Michele J Patterson ◽  
Tracy Moore ◽  
Paula Cline ◽  
Lee Birnbaum
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Community Education ◽  
Stroke Severity ◽  
Complication Rates ◽  
Stroke Treatment ◽  
Stroke Disability ◽  
Treatment Window

Background: After clinical practice guidelines extended the mechanical endovascular reperfusion [MER] window, our Comprehensive Stroke Program expanded its stroke alert [SA] to include last known well [LKW] 6-24 hours [h]. Expansion included implementation of a standardized large vessel screen, RAPID brain imaging software, revised algorithm, EMS and community education, and regional transfer guidelines. Purpose: Evaluate outcomes of the extended window [EW] for ischemic stroke treatment. Method: We reviewed ischemic strokes over a 2 year period and categorized them into two groups: 2017 pre-guideline [PG] and 2018 EW post-guideline [PostG]. Each group was divided into all-MERs and MERs 6-24h. Groups were compared by LKW, NIHSS, TICI scores, complications, discharge [DC] disposition and Modified Rankin Score [mRS] at DC and 90 days [90d]. Outcomes were evaluated to identify the EW impact. Results: Of 744 strokes reviewed, 365 were PG and 379 were EW PostG. LKW 6-24h was greater PostG [22%=PG versus [v] 30%=EW], in all-MERs [19%=PG v 31%=EW] and MERs 6-24h [69%=PG v 83%=EW]. Stroke severity [NIHSS>7] was higher PostG [41%=PG v 45%=EW], in all-MERs [88%=PG v 91%=EW] and MERs 6-24h [85%=PG v 96%=EW]. MER treatment rates increased PostG [13%=PG v 17%=EW]. Post-MER TICI 2b/3 reperfusion rates were higher PostG in all-MERs [63%=PG v 77%=EW] and MERs 6-24h [38%=PG v 71%=EW]. Any complication was lower PostG [27%=PG v 22%=EW] with higher complication rates in MERs 6-24h [15%=PG v 17%=EW]. More patients were DC home PostG [42%=PG v 46%=EW], in all-MERs [25%=PG v 30%=EW], and MERs 6-24h [8%=PG v 29%=EW]. mRS 0-2 at DC was increased PostG [20%=PG v 29%=EW], in all-MERs [12%=PG v 27%=EW], and MERs 6-24h [8%=PG v 34%=EW]. mRS at 90d was increased PostG for all-MERs [25%=PG v 34%=EW] with decreased deaths [15%=PG v 10%=EW]. Conclusion: The EW has increased patients treated and improved overall outcomes. Patients arriving with LKW 6-24h has increased along with stroke severity. Reperfusion rates improved and overall complications were lower, however higher rates were seen in MERs 6-24h. Patients treated in the EW had reductions in post stroke disability, increases in DC to home, and improvements in mRS at DC and 90d.

Primary Stroke Prevention in Nonvalvular Atrial Fibrillation: Implementing the Clinical Trial Findings

1997 ◽  
Vol 31 (10) ◽  
pp. 1187-1196 ◽  
Author(s):  
Patricia A Howard ◽  
Pamela W Duncan
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Trial ◽  
Clinical Trials ◽  
Clinical Practice ◽  
Cost Effectiveness ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Randomized Clinical Trials ◽  
Nonvalvular Atrial Fibrillation ◽  
Risk Patients

OBJECTIVE: To review the clinical trials evaluating warfarin for primary stroke prophylaxis in nonvalvular atrial fibrillation (NVAF), to discuss the relative benefits and risks of warfarin versus aspirin therapy, and to review the clinical practice guidelines and identify potential barriers to their implementation in clinical practice. DATA SOURCES: A MEDLINE literature search was performed to identify clinical trials of antithrombotic therapy for NVAF, clinical practice guidelines, studies evaluating physician practices and attitudes, cost-effectiveness studies, and pertinent review articles. Key search terms included atrial fibrillation, stroke, antithrombotic, warfarin, aspirin, and cost-effectiveness. DATA EXTRACTION: Prospective, randomized clinical trials were selected for analysis. Clinical practice guidelines from recognized panels of experts were reviewed. Comprehensive review articles were selected. DATA SYNTHESIS: NVAF is a common arrhythmia that is associated with a substantial risk for stroke. Seven prospective, randomized, clinical trials have conclusively demonstrated the efficacy of warfarin for stroke prevention. The greatest benefits are achieved in older patients and those with comorbidities that increase their risk for stroke. The potential benefits of preventing a devastating stroke, however, must be weighed against the potential for bleeding complications. Warfarin has been shown to be cost-effective in high-risk patients, provided the rate of complications is minimized. Nonetheless, many physicians remain hesitant to implement warfarin therapy in older, high-risk patients. The clinical data on aspirin are less consistent than those observed with warfarin. Aspirin appears to be most effective in younger individuals or those considered to be at low risk for stroke. CONCLUSIONS: In patients with NVAF, the personal, social, and economic consequences of stroke are often devastating. Clinical trials have provided definitive proof that the risks of stroke can be significantly reduced through the use of appropriate antithrombotic therapy. Despite this evidence and the recommendations of a number of clinical practice guidelines, variations in care exist that continue to place patients at risk. Additional outcomes research is needed to evaluate the impact of the clinical trial findings and practice guidelines on clinical practice and to develop methods for overcoming barriers to implementation.

Intravenous Thrombolysis in Acute Ischemic Stroke

2018 ◽  
pp. 128-152
Author(s):  
Waldo R. Guerrero ◽  
Edgar A. Samaniego ◽  
Santiago Ortega
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
American Heart Association ◽  
American Heart ◽  
Time Window ◽  
Intravenous Thrombolysis ◽  
Heart Association ◽  
Standard Of Care

The only proven therapy for patients with acute ischemic stroke is early recanalization. The use of intravenous thrombolytic alteplase is the standard of care for patients presenting with ischemic stroke within the first 4.5 hours from symptom onset. This chapter reviews the indications and contraindications to alteplase including the 2015 American Heart Association guidelines and their relevance to clinical practice. Furthermore, emerging research and ongoing trials on expanding the time window for intravenous thrombolysis are discussed.

Sign in / Sign up

Export Citation Format

Share Document