dont mix up mechanical thrombectomy and chemical thrombolysis

1:28 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

kellert et al have published a very important article...which is seen in day to day practice....and which I have kept telling to anyone I meet and cares to listen to me....which is "DO ONLY MECH THROMBECTOMY AND DONT MIX UP DIFFERENT TECHNIQUES OF RECANALISATION"

 
if a vessel gets recanalised by the aspiration and the solitaire device, its well and good, but pushing in antiplatelet drugs or even rTPA in case of failure or for recanalising distal branches, is not a very good idea, as it results in haemorrhage a lot of times.
 
The reason is not clear but the observation is.. however some hypotheses can definitely be made.
1. GOD does not want this patient to improve !
2. there is distal vessel occlusion and insitu thrombus formation apart from the large vessel occlusion,
3. 'no-reflow' phenomenon
4. poor collateral
5. the parenchymal territory is already damaged irreversibly
6. the mech device has opened the larger proximal artery resulting in hyperperfusion, and the drug directly is toxic to cells, thus resulting in enhanced bleeding ....
 
most likely a combination of all these is happening....
What I am getting to in acute stroke intervention in my short career is that if a patient comes with acute stroke---
1. be aggressive with intravenous thrombolysis.
2. if CT/MRI/CTA/MRA/CTP show large vessel occlusion with favourable ASPECT score (plus good leptomeningeal score or large mismatch, as per availability of data), the go straight for aspiration and mechanical thrombectomy.... and forget about chemical intravenous or intraarterial thrombolysis
3. however, if the interventionist is not comfortable with mech devices then combined IVT+IAT should be done wherever possible.
 
the link and the abstract are given underneath
 
Kellert et al. Tirofiban Is Associated With Risk of Fatal Intracerebral Hemorrhage and Poor Outcome. Stroke. 44: 1453-1455 Published online before print March 5, 2013, doi: 10.1161/​STROKEAHA.111.000502
 

Abstract

Background and Purpose—To investigate the relationship between severe bleeding complications and outcome after mechanical thrombectomy with or without glycoprotein-IIb/IIIa inhibitor tirofiban treatment.
Methods—The study included prospectively collected data of consecutive patients with acute ischemic stroke in whom mechanical thrombectomy was perfomed in the years 2006 to 2011.
Results—Of 162 patients, 128 patients had anterior circulation stroke, and 34 patients had posterior circulation stroke. Additional treatment with tirofiban was given to 30 of 128 patients with anterior circulation stroke and to 20 of 34 patients with posterior circulation stroke. Treatment with tirofiban did not influence recanalization rates. Fatal intracerebral hemorrhage occurred more frequently in tirofiban-treated patients in the entire cohort (12.0% vs 2.7%; P=0.03) and in tirofiban-treated patients with anterior circulation stroke (13.3% vs 3.1%; P=0.05). Logistic regression found age (odds ratio, 1.17; 95% confidence interval, 1.00–1.37; P=0.05) and tirofiban treatment (odds ratio, 3.03; 95% confidence interval, 1.50–4.05; P=0.04) to be independent predictors for fatal intracerebral hemorrhage. Tirofiban treatment was also an independent predictor for poor outcome (odds ratio, 6.60; 95% confidence interval, 1.06–41.52; P=0.04) in addition to National Institute of Health Stroke Scale (odds ratio, 1.08; 95% confidence interval, 1.00–1.17; P=0.05).
Conclusions—In endovascular stroke therapy, additional treatment with the glycoprotein-IIb/IIIa inhibitor tirofiban is associated with increased risk of fatal intracerebral hemorrhage and poor outcome.
 
 
 
 


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reason for being inactive

1:13 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

folks, I was relocating to a new place, 1000 KM away in this vast country called INDIA, hence could not add any posts for two months.
I shall restart posting now.
But no cases...for now...because the department is not set...shall be at least another 6 months.


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How to determine suitability of thrombolysis in acute stroke

6:28 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Disclaimer: This is a difficult topic and you may find the points given above varying from the standard 'GUIDELINES'. I would like to say that this is what we "PRACTICE' with the patients/attendants consent which is mandatory.


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Heme Iron Intake and Risk of Stroke: Long live the vegans

4:24 PM Posted by Dr Subhash Kumar, MBBS, MD, DM

Heme Iron Intake and Risk of Stroke; A Prospective Study of Men

  1. Susanna C. Larsson, PhD
http://stroke.ahajournals.org/content/44/2/334.abstract?sid=5e018478-80dc-4701-a54c-a9308ab34a36
     

    Abstract

    Background and Purpose—Intake of iron, especially heme iron, has been associated with several diseases. However, epidemiological studies of heme iron and nonheme iron intake in relation to risk of stroke are lacking. The aim of this study was to examine the associations between heme iron and nonheme iron intake and stroke incidence in men.
    Methods—The population-based prospective Cohort of Swedish Men included 38 859 men, aged 45 to 79 years, who had no history of stroke, coronary heart disease, or cancer at baseline. Hazard ratios and 95% confidence intervals (95% CIs) were calculated using Cox proportional hazards regression models.
    Results—During an 11.7 years follow-up, 3097 incident cases of stroke, including 2482 cerebral infarctions and 450 intracerebral hemorrhages, were registered. The hazard ratios of total stroke and cerebral infarction for the highest compared with the lowest quintiles of heme iron intake were 1.16 (95% CI, 1.03–1.31; P trend=0.037) and 1.15 (95% CI, 1.00–1.31; P trend=0.089), respectively. The incidence rates of total stroke per 10 000 person-years were 72.6 in the lowest quintile and 84.4 in the highest. The association was confined to men with body mass index <25 kg="kg" m="m" sup="sup">2
, the hazard ratios were 1.40 (95% CI, 1.17–1.68; P trend<0 .001=".001" 1.13="1.13" 1.38="1.38" and="and" ci="ci" em="em" for="for" stroke="stroke" total="total">P trend=0.001) for cerebral infarction; no association was observed among overweight and obese men. There was no association between nonheme iron intake and risk of total stroke and stroke types.
Conclusions—Findings from this prospective study indicate that a high heme iron intake, particularly in normal weight individuals, may increase the risk of stroke.


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