Stroke

According to the data provided by American heart/stroke association, Approximately 795000 strokes occur in the United States each year. On average, every 40 seconds, someone in the United States has a stroke, and on average, every 4 minutes, someone dies of a stroke.

 

Stroke is the second-leading cause of death accounting for 6.5 million stroke deaths worldwide in 2013.

 

Women have a higher lifetime risk of stroke than men. Black women had higher annual rates of first-ever stroke than black men for ages ≥75 years.

 

In 2014 — On average, every 4 minutes, someone died of a stroke. Stroke accounted for ≈1 of every 20 deaths in the United States in 2014.

 

For almost 2 decades, IV tpa since its approval by FDA in 1996, remained the only treatment option for patients experiencing acute ischemic stroke presenting to the ER within 3 hour time window (with a select group of patients eligible to be treated within 4.5 hrs of symptom onset).

 

Before December 2014, the only proven effective treatment for acute ischemic stroke was recombinant tissue-type plasminogen activator (r-tPA).

This has now changed with the publication of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE), Extending the Time for Thrombolysis in Emergency Neurological Deficits—Intra-Arterial (EXTEND IA), Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment Trial (SWIFT PRIME), and Randomized Trial of Revascularization With the Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset (REVASCAT) studies

 

The main take home points from these trials are:

 

(1)  Intra-arterial thrombectomy is a potently effective treatment and should be offered to patients who have documented occlusion in the distal internal carotid or the proximal middle cerebral artery, have a relatively normal noncontrast head computed tomographic scan, severe neurological deficit, and can have intra-arterial thrombectomy within 6 hours of last seen normal;

 

(2)  Benefits are clear in patients receiving r-tPA before intra-arterial thrombectomy; r-tPA should not be withheld if the patient meets criteria,

 

(3)  These favorable results occur when intra-arterial thrombectomy is performed in an endovascular stroke center by a coordinated multidisciplinary team that extends from the prehospital stage to the endovascular suite, minimizes time to recanalization, uses stent-retriever devices, and avoids general anesthesia.

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