Endovascular therapy after intravenous t-PA versus t-PA alone for stroke

Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, et al; Interventional Management of Stroke (IMS) III Investigators.
N Engl J Med. 2013 Mar 7;368(10):893-903. doi: 10.1056/NEJMoa1214300. Epub 2013 Feb 7.

LINK TO ABSTRACT

Endovascular treatment for acute ischemic stroke

Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, Boccardi E; SYNTHESIS Expansion Investigators.
N Engl J Med. 2013 Mar 7;368(10):904-13. doi: 10.1056/NEJMoa1213701. Epub 2013 Feb 6.

LINK TO ABSTRACT

Compared IV t-PA vs endovascular treatment

These two studies compared the use of IV t-PA versus the use of various endovascular devices to remove the clot or direct intra-arterial t-PA in higher concentrations directly at the thrombotic lesions.

Both of these studies demonstrated that when compared head to head, there was no difference in functionality or mortality between the two methods.

No functional differences in outcomes 

Why should the prehospital folks care?

Many hospitals are moving toward having a neuro-interventionalist available to direct a catheter to dissolve or remove the clot from culprit lesion.  They have demonstrated improved flow and other process improvements and were tantalizing in their potential promise in this still dismal disease.  This could drive the need for comprehensive stroke centers similar to our STEMI system.

It was hoped and feared that this resource intensive method would be substantially better and would drive the need for comprehensive stroke centers similar to our STEMI system.

Death knell for comprehensive stroke centers

These two studies drove a large stake in the heart of the concept of comprehensive stroke centers.  There will be a steady search for subgroups that do better such as late presenters or those with other contraindications for systemic t-PA.

As a health system, our successes in stroke treatment have been very modest as compared to STEMI care.  For every 100 suspected strokes presenting to a primary stroke center, only 9-30% of cases receive t-PA.

For every 100 suspected strokes presenting to a primary stroke center, only 9-30% of cases receive t-PA.

Many are excluded for a large variety of reasons such as time of onset, hemorrhagic stroke, and other contraindications.  But there is still a large variation among hospitals in this rate. This should be a focus of each hospital’s QI prgram.

Stroke Systems have not shown any improvement in the rate of t-PA administration.

Dr. Sporer is the EMS Medical Director for Alameda County

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