Cerebrovascular Disease

Systems of stroke care continue to reorganize in response to access to endovascular intervention (clot retrieval/thrombectomy) and the ever-changing time windows for treatment. Persistent questions remain regarding the necessity of alteplase prior to early endovascular intervention. The DIRECT-MT trial provided some of the most robust evidence to date, suggesting only the smallest advantages in reperfusion from alteplase administration.⁹ Reperfusion, however, remains a surrogate for measurably improved clinical outcomes, and once taking adverse events into account, the overall picture appears to favor endovascular intervention alone. It should be considered reasonable to skip alteplase prior to endovascular intervention, but these data may be rendered moot as Tenecteplase (which is given more quickly and thus creates fewer delays) gradually replaces alteplase.

Screening patients for subarachnoid hemorrhage remains a challenge, despite multiple validations of the Ottawa Subarachnoid Hemorrhage Rule. Developed as a zero-miss screening tool, the specificity of this decision instrument creates challenges in implementation. In a recent study, practice patterns were evaluated before and after implementing routine use of the Ottawa rule and a six-hour CT rule.¹⁰ Overall, few differences were observed, likely owing to prestudy familiarity with both changes (ie, many clinicians had already altered their practices prior to any “official” implementation practices). However, a handful of interesting missed cases were noted, including one in a profoundly anemic patient, rendering the Ottawa rule less than zero-miss in some rare circumstances. When using noncontrast CT to exclude subarachnoid hemorrhage, consider contributors to false-negative scans.

See you next year!

The opinions expressed herein are solely those of Dr. Radecki and do not necessarily reflect those of his employer or academic affiliates. 

References

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