Stroke Briefing: 5 New Things to Know

In patients recovering from stroke, adding minimally invasive stent thrombectomy to standard clot-dissolving therapy with tPA dramatically restores blood flow to the brain. In one study, 70 patients received endovascular therapy + alteplase (35 patients) or alteplase-only (35 patients). In patients who received stent thrombectomy, 89% had blood flow restored vs 34% of patients who had standard clot-dissolving therapy alone. The addition of stent thrombectomy to standard clot-dissolving treatment led to 71% of patients returning to independent living vs 40% in the standard treatment group. (Dr Bruce Campbell and Associate Professor Peter Mitchell: EXTEND-IA research study.)

Delayed consent is one of the most common reasons stroke patients do not receive tPA within the first hour of arrival to the hospital. In a study of more than 22,000 patients with ischemic stroke at 120 New York hospitals, delays in tPA administration occurred in 1,145 patients. Reasons included patient/family consent (21%) and other emergency health conditions (21%). Women were much more likely to experience delay due to patient/family consent than men. Delay due to patient/family consent was more likely on weekends. (Abstract 206 and Abstract 14)

Patients with a poor prognosis after intracerebral hemorrhage frequently do not receive appropriate palliative care consultations while in the hospital. Of 99 patients who died or were discharged to hospice, only 23% received palliative care consultation. Among those with the most severe intracerebral hemorrhage, only 28% received a palliative care consult, despite an expected 30-day mortality of 97%. These findings raise concerns about the underuse of palliative care among patients who might benefit the most. (Abstract 68)

Stroke patients with mild symptoms often don't receive tPA because they are deemed "too good to treat." Researchers at Boston's Massachusetts General Hospital found that among more than 2,700 stroke patients considered for tPA, nearly 240 patients arrived in time to receive tPA but did not receive it because their symptoms were too mild or they were rapidly improving; of these patients, 89 patients did not do well and might have benefitted from tPA. Risk factors for having poor outcome post-stroke included advanced age; having more severe strokes; being Hispanic; and having a stroke that affected both hemispheres. (Khawja A. Siddiqui, MD).

Using ultrasound to measure the sheath of the optic nerve can help identify patients with acute stroke at greatest risk of dying. Optic ultrasound is a safe, routine bedside test performed using gel and a device placed on closed eyelids. Measuring optic nerve sheath thickness may be a simple test for increased intracranial pressure. Researchers used ocular ultrasound to measure the optic nerve sheath in 86 patients suspected of having elevated intracranial pressure post-stroke. For every mm bigger the nerve sheath diameter was, the risk of death within 6 months was 4 times as high in patients whose stroke was due to a blood vessel blockage, and 6 times as high in patients who had a hemorrhagic stroke.