image by: HWN

HWN Suggests

Einstein and the Brain: The Relativity of Time in Ischemic Stroke Treatment

In Einstein’s theory of relativity, time is relative; it depends on speed and gravity and differs for each observer. Is time also crucial for the brain, especially during a stroke? The concept of “time is brain” emerged in 1995, highlighted by the NINDS study, which showed that intravenous thrombolysis (IVT) within the first 3 hours of acute ischemic stroke (AIS) symptoms significantly improves outcomes. Since then, guidelines have expanded this window to 4.5 hours for eligible patients. Yet, only about 30% of stroke patients arrive at this early “time window.” For those arriving later, mechanical thrombectomy (MT) has shown high effectiveness, but access remains limited in low-income regions.…

read full article

Featured

 Paradigm Shift in Ischemic Stroke Management Part 1: Disabling Strokes

We are amidst a paradigm shift in the emergency management of acute ischemic stroke. The traditional way of categorizing ischemic strokes as ‘minor’ vs ‘major’ is no longer relevant to what we do in the ED. It’s now about ‘disabling’ vs ‘non-disabling’ strokes. And this is no small change. This categorization dictates urgency of ED work-up and treatments, imaging choices, treatment decisions and goals of care

Articles of Interest

Ischemic stroke: the workup and the clock

The neuro exam alone cannot distinguish ischemic from hemorrhagic stroke, imaging is required before any treatment decision. Noncontrast head CT is the initial test. It is often normal early in ischemic stroke, even up to 24 hours, especially for small or brainstem infarcts. That is expected and does not change your management. MRI is more sensitive (diffusion-weighted imaging can show changes within minutes), but its long acquisition time means it is not the first test and is not used to make thrombolysis decisions in most patients.

New Findings Could Save Lives of More Stroke Patients

Many more stroke victims than previously thought can be saved from disability or death if doctors remove blood clots that are choking off circulation to the brain, a new study has shown.

What You Should Know About Ischemic Stroke

With a brain attack, every second counts.

Conversations in Arterial Ischemic Stroke

Conversations in Arterial Ischemic Stroke provides an in-depth look at novel treatments and new studies. Check in frequently for exclusive video interviews, Q&A’s and expert commentary on key issues facing clinicians today.

CRAO: Harbinger of Ischemic Stroke

Since becoming a neuro-ophthalmologist several years ago, Dr. Levin said his attitude toward conditions such as CRAO has changed dramatically. “To me, the key is secondary prevention—minimizing the risk of hemispheric stroke.”

For First Time, Treatment Helps Patients With Worst Kind of Stroke, Study Says

After three decades of failure, researchers have found a treatment that greatly improves the prognosis for people having the most severe and disabling strokes. By directly removing large blood clots blocking blood vessels in the brain, they can save brain tissue that would have otherwise died, enabling many to return to an independent life.

For Many Strokes, There’s an Effective Treatment. Why Aren’t Some Doctors Offering It?

A charismatic, riveting speaker, Dr. Hoffman has given educational courses across the country and many medical professionals have listened to informational tapes in which he presented his critique of the evidence. And his influence has spread.

Ischemic Stroke Recovery Guide

It’s important to remember that a stroke has the potential to harm a subject in several ways. Not only are there many possible physical side effects, but mental and emotional complications can also surface because of an attack. However, the seriousness of these issues is determined by the severity of the stroke itself, and the nature of the issues may vary depending on what parts of the brain are affected.

Ischemic stroke: what’s the right treatment?

Stroke is a leading cause of disability and death. You may often hear the phrase “Time is brain,” a call-to-action for swift, lifesaving treatment as soon as you recognize a symptom of stroke. There have been several treatment advancements for stroke, including thrombectomy, which have resulted in improved outcomes for patients. But not every person gets the same stroke treatment; even though a stroke is a medical emergency, some people don’t require immediate treatment.

Ischemic Stroke–A Scientometric Analysis

Ischemic strokes are further divided into lacunar and non-lacunar infarcts, the latter also into various subgroups such as cardioembolic, cryptogenic, or occlusion of a major artery. In ~17% of all patients with ischemic strokes, the exact cause remains elusive [so called embolic stroke of undetermined source (ESUS)].

Nondisabling Stroke Recognition and Management

Nondisabling stroke is where Emergency Medicine earns its keep. The threats are quieter, the windows are wider, and the misses—especially in younger and female patients—are more common. In this Part 2 or our 2-part podcast update on ED stroke management with Dr. Katie Lin and Dr. Walter Himmel we explore non-disabling strokes, where symptoms are mild enough that patients can continue daily activities if deficits persist. Yet, non-disabling does not mean benign. Nondisabling strokes occupy the same ischemic continuum as high risk TIAs and carry a substantial risk of early recurrent disabling stroke.

Popular heartburn medication may increase ischemic stroke risk

"At one time, PPIs were thought to be safe, without major side effects," he said, "This study further questions the cardiovascular safety of these drugs."

This Revolutionary Stroke Treatment Will Save Millions of Lives. Eventually.

A procedure called EVT is creating radically better outcomes for patients, but only when it’s performed quickly enough — and that requires the transformation of an entire system of care.

Time is Brain – Acute Ischemic Stroke Part 2: Mechanical Thrombectomy

Mechanical thrombectomy has revolutionized stroke care for patients with large vessel occlusions (LVOs). LVOs account for ~40% of all AIS, and prior to endovascular therapy more than half of these patients suffered significant post-stroke disability (modified Rankin Scale (mRS) 4-5) or death (mRS 6). This post reviews who qualifies for mechanical thrombectomy, the process of screening, and how the field of interventional neurology continues to evolve.

Time is Brain – Acute Ischemic Stroke Part I: Vascular Syndromes and Thrombolysis

About ~800K people have a stroke in the US every year (1 person every 40 seconds) and stroke is a leading cause of serious long-term disability (PMID: 31992061). But prior to ~2015, outside of trials, the acute ischemic stroke patient either arrived within 4.5 hours and got tPA or they got supportive care. And, unfortunately, very few patients arrive within the 4.5 hour time window. Things are dramatically different now. The endovascular era in stroke care has revolutionized care for patients with large vessel occlusions (LVO) – which is the subgroup of patients that before the reperfusion era accounted for the highest stroke morbidity and mortality. There is now effective treatment for those who present within 24 hours.

tPA for Acute Ischemic Stroke and Its Controversies: A Review

Although neurologists consider intravenous tissue plasminogen activator (tPA) to be standard of care in the treatment of patients with acute ischemic stroke, its use remains contentious within the broader medical community, and particularly among emergency physicians. Why might this be? We provide a historical context to this ongoing controversy by reviewing how neurologists have conceptualized the acute stroke and its treatment, with the aim of bridging this gap.

Understanding the Pathophysiology of Ischemic Stroke: The Basis of Current Therapies and Opportunity for New Ones

Factors such as the complexity of ischemic injury, heterogeneity of patient population, limited therapeutic window for effective neuroprotection, and unforeseen side effects make translating experimental findings to clinical therapies a challenge. Considering the multifactorial nature of ischemic injury, exploring combination therapies that target multiple pathways simultaneously may enhance the likelihood of success in clinical translation. Moreover, refining the preclinical stroke models to better mimic the complexity of human stroke may increase the predictive value of preclinical studies.

Resources

StatPearls

Acute ischemic stroke, previously referred to as a cerebrovascular accident, is a medical emergency characterized by the sudden onset of focal neurological deficits within a specific vascular territory, resulting from underlying cerebrovascular disease. Ischemic stroke, the most common type of stroke, is caused by thrombotic or embolic occlusion that reduces blood flow to the brain. The condition places a substantial burden on public health systems and individuals and remains a leading cause of morbidity and mortality worldwide.

UpToDate

The use of thrombolytics for acute stroke requires care in a hospital that is able to coordinate emergency services and offers rapid consultation with a neurologist (physician who specializes in the brain) and has intensive care services and imaging (eg, CT scan or MRI). Not all hospitals are able to provide these services, and in this situation it may be necessary to transfer the patient to a hospital that can. It is best if the ambulance or family can bring the stroke patient directly to a hospital that is able to give this care, rather than to transfer the patient later. Side effects – Overall, it is estimated that alteplase treatment is 10 times more likely to help than to harm. However, approximately 1 in 15 patients who is given thrombolytic therapy develops excessive bleeding (hemorrhage) in the brain; this type of bleeding can be fatal. It is estimated that of 30 patients treated, one is harmed by the treatment