TWO ACES: Transient Ischemic Attack Work-Up as Outpatient Assessment of Clinical Evaluation and Safety
The addition of diffusion-weighted imaging and vascular imaging to the ABCD2 score has been shown to improve the ability to discriminate patient with high versus low stroke risk transient ischemic attack (TIA) and allow for more accurate triaging of high-risk patients to hospitalization. Olivot and colleagues assessed whether this approach in conjunction with rapid TIA clinic access (ideally within 1 to 2 days) after first presentation may reduce hospitalization rates as well as stroke rates to lower than predicted by the ABCD2. Patients with an ABCD2 score of 0 to 3 or 4 to 5 without symptomatic arterial stenosis (>50% narrowing) were preferentially referred to the TIA clinic (n=157), whereas patients with a score of 6 to 7 were admitted (n=67) regardless of vessel status. Deviation from this protocol was allowed per treating physician's discretion. Stroke, myocardial infarction, and vascular death were assessed at 7, 30, and 90 days. Of 224 patients, 52% had a final diagnosis of stroke/TIA. After exclusion of prespecified parameters (ABCD2 score and parameters included in it as well as vessel status), prior myocardial infarction and atrial fibrillation were independently associated with hospitalization. The rate of vascular outcome events for TIA clinic-referred versus hospitalized patients was 0.6% versus 1.5% at 7 days without further events at later time points, respectively. The authors hypothesize that these lower than expected stroke rates might have been related to early secondary prophylaxis in a selected and possibly more homogeneous study population with higher socioeconomic status than comparison populations. However, the authors acknowledge that they did not assess adherence to secondary prophylaxis and that the rate of confirmed vascular events was modest. If confirmed in larger, prospective multicenter trials with similar triage/follow-up concepts, unnecessary hospitalizations may be avoided and thus reduce the overall cost. However, given the observed high rate of patients without cerebrovascular events, it will be important to show that such an approach would not delay appropriate workup and thus potentially harm these patients. See p 1839.
Three-Month and Long-Term Outcomes and Their Predictors in Acute Basilar Artery Occlusion Treated With Intra-Arterial Thrombolysis
Basilar artery occlusion is arguably the most dreaded acute stroke syndrome given its poor response to treatment and dismal prognosis with persistent occlusion. Endovascular approaches to revascularization are frequently thought to improve outcome through higher revascularization rates. Jung and colleagues sought to identify predictors of treatment effects and clinical outcome in 106 patients with acute basilar artery occlusion subjected to intra-arterial urokinase and/or mechanical thrombectomy. Respective complete (Thrombolysis In Myocardial Ischemia 3) and partial (Thrombolysis In Myocardial Ischemia 2) recanalization was achieved in 52% and 18% of patients. A good or moderate outcome (modified Rankin Scale 0 to 3) was noted in approximately 40% of patients at 3 months and 3.1 years (median long-term followup), respectively. From 3-month to long-term follow-up, 22 patients (40.8%) showed clinical improvement (decline in modified Rankin Scale by at least 1 point) and 29 (53.7%) remained unchanged. Symptomatic intracerebral hemorrhage occurred in 1 patient (0.9%). Although the presented data suffer from all limitations associated with a retrospective, single-center analysis, it adds to the notion that endovascular approaches can be safely applied to achieve high recanalization rates and a good to moderate outcome in a significant number of patients. Because no direct comparison to other treatment modalities such as intravenous thrombolysis or anticoagulation was performed, it remains to be shown that an endovascular approach truly provides superior outcomes. Nevertheless, this study provides important information that recovery beyond 3 months is seen in a substantial subset of patients. Unfortunately, predictors of improvement beyond 3 months were not assessed, yet given the overall poor outcome, such knowledge is critical for prognostication and patient/family education and future analysis may shed further light on this issue. See p 1946.
Recombinant Tissue-Type Plasminogen Activator Use for Ischemic Stroke in the United States: A Doubling of Treatment Rates Over the Course of 5 Years
Increasing the use of tissue plasminogen activator remains an important goal for acute ischemic stroke care. Previous estimates indicated the rate of recombinant tissue plasminogen activator use in the United States to be 1.8% to 2.1% of patients with ischemic stroke in 2004. Using identical methodology to the prior study, Adeoye and colleagues now present an update on tissue plasminogen activator use for ischemic stroke from 2005 to 2009 in the United States based on the Medicare Provider and Analysis Review data set (International Classification of Diseases, 9th Revision codes) and the Premier Hospital database (pharmacy billing codes). Thrombolytic use was similar in both the Medicare Provider and Analysis Review and Premier groups during the study period. Overall, the rate of thrombolytic use for all patients within Premier increased from 2.4% in fiscal year 2005 to 4.5% in fiscal year 2009 (P<0.001). Using the most conservative estimate, thrombolytic use in 2009 was 3.4%. Inclusion of patients who were miscoded as TIA or hemorrhagic stroke increased the estimated rate of thrombolytic therapy to 5.2%, which corresponds to approximately 36 000 patients (based on approximately 700 000 strokes per year in the United States). Suggested reasons for this increase include initiatives to standardize stroke care and less likely greater reimbursement for hospitals. Among the limitations of this study are coding through nonmedical personnel, unknown mode of tissue plasminogen activator delivery, and unknown appropriateness of patient selection for treatment. Regardless, assuming similar patient and treatment characteristics, the presented numbers are a very encouraging signal that the only Food and Drug Administration-approved therapy was made available to twice as many patients compared with pre-2005 years, yet the nationwide numbers still fall far behind that of dedicated stroke centers and continued efforts are required to further the use of tissue plasminogen activator for advanced acute ischemic stroke care. See p 1952.
- © 2011 American Heart Association, Inc.
- TWO ACES: Transient Ischemic Attack Work-Up as Outpatient Assessment of Clinical Evaluation and Safety
- Three-Month and Long-Term Outcomes and Their Predictors in Acute Basilar Artery Occlusion Treated With Intra-Arterial Thrombolysis
- Recombinant Tissue-Type Plasminogen Activator Use for Ischemic Stroke in the United States: A Doubling of Treatment Rates Over the Course of 5 Years
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