2/13/2015 Overview • Non-endovascular treatment of Acute Ischemic Stroke International Stroke Conference • Stroke prevention Update 2015 • Stroke rehabilitation Nerissa U. Ko, MD, MAS University of California, San Francisco Recent Advances in Neurology February 13, 2015 Nothing to disclose Clot buster use rises most among 80 and older stroke patients • Michelle P. Lin, M.D., M.P.H., University of Southern California, Los Angeles, Calif. • Researchers analyzed the health records of nearly 6 million patients admitted to U.S. hospitals between 2000 and 2010 for strokes treated with IV tPA • Study participants were 35 percent 80 years ACUTE STROKE and older, 37 percent 65 to 79 years of age, and 28 percent were 18 to 64. 1
2/13/2015 Many mild stroke patients considered “too good Clot buster use rises most among 80 to treat” may actually benefit from tPA and older stroke patients • They found that tPA administration rate increases • Stroke patients with mild symptoms might be from 2000 to 2010 were: eligible but often don’t receive tPA because they are deemed “too good to treat”, but many of • 0.47 to 3.55 percent for the oldest group studied; these patients don’t fare well after stroke • 0.92 to 3.87 percent for 65 to 79 year olds; and • Using the Get With The Guidelines database from • 1.02 to 3.61 percent in patients ages 18 to 64. Boston’s Massachusetts General Hospital, • Among age >80, those treated at an urban researchers analyzed 2,745 consecutive stroke hospital and teaching hospital were more likely to admissions (01/2009 - 07/2013) to identify which receive tPA. “too-good-to treat”-patients should be • Women, Blacks, Hispanics and Medicaid holders considered for tPA because of their risk of poor were less likely to receive tPA. health or death. Many mild stroke patients considered “too good Patients with “wake-up strokes” may to treat” may actually benefit from tPA be candidates for tPA treatment • Andrew D. Barreto, M.D., The University of Texas • 238 stroke patients arrived in time to receive tPA but Health Science Center at Houston, TX. did not receive it because their symptoms were too mild or they were rapidly improving • N=40 moderate severity wake-up stroke patients with a broad range of stroke severities and • 89 did not do well and might have benefitted from tPA. disabling deficits. – Only 62 percent were discharged home • Patients received tPA an average of 2.6 hours – 27 percent went to inpatient rehabilitation facilities after waking up with stroke symptoms. – 8.4 percent to skilled nursing facilities • None of the patients treated had intracerebral – more than 2 percent either died or went to hospice. hemorrhage, resulting in neurological worsening. • Risk factors for having poor outcome: elderly; more severe strokes; Hispanic;stroke that affects both • 50% made full recoveries at 90 days. hemispheres 2
2/13/2015 STROKE PREVENTION Atrial fibrillation and Cryptogenic stroke Atrial fibrillation and Cryptogenic stroke • To help determine if an implantable cardiac • Half of the patients with detected atrial monitor (ICM) is effective, researchers fibrillation had an episode that was at least analyzed 1,247 cryptogenic stroke patients 3.4 hours in duration. who received an ICM device post stroke • Among the patients with atrial fibrillation, 25 • Atrial fibrillation detection rate in the study percent had an episode that was longer than population was 12.2 percent at 182 days; this 11.8 hours. was 37 percent higher than what was found in • ICMs may have even greater clinical utility in a recent randomized controlled trial (CRYSTAL detecting AF in real-world practice than in AF) at the same time. clinical trials. 3
2/13/2015 Atrial fibrillation and Cryptogenic stroke • Scientists analyzed data from previous studies to determine if detecting atrial fibrillation with an ICM in cryptogenic stroke patients is cost- effective compared to standard of care. • ICM was associated with fewer recurrent strokes and increased quality of life • While stroke-related costs were lower in the ICM group, overall costs were higher than in the standard of care group 4
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2/13/2015 REHABILITATION 6
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