Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke.

BACKGROUND: Intravenous infusion of alteplase is used for thrombolysis before endovascular thrombectomy for ischemic stroke. Tenecteplase, which is more fibrin-specific and has longer activity than alteplase, is given as a bolus and may increase the incidence of vascular reperfusion. METHODS: We randomly assigned patients with ischemic stroke who had occlusion of the internal carotid, basilar, or middle cerebral artery and who were eligible to undergo thrombectomy to receive tenecteplase (at a dose of 0.25 mg per kilogram of body weight; maximum dose, 25 mg) or alteplase (at a dose of 0.9 mg per kilogram; maximum dose, 90 mg) within 4.5 hours after symptom onset. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiographic assessment. Noninferiority of tenecteplase was tested, followed by superiority. Secondary outcomes included the modified Rankin scale score (on a scale from 0 [no neurologic deficit] to 6 [death]) at 90 days. Safety outcomes were death and symptomatic intracerebral hemorrhage. RESULTS: Of 202 patients enrolled, 101 were assigned to receive tenecteplase and 101 to receive alteplase. The primary outcome occurred in 22% of the patients treated with tenecteplase versus 10% of those treated with alteplase (incidence difference, 12 percentage points; 95% confidence interval [CI], 2 to 21; incidence ratio, 2.2; 95% CI, 1.1 to 4.4; P=0.002 for noninferiority; P=0.03 for superiority). Tenecteplase resulted in a better 90-day functional outcome than alteplase (median modified Rankin scale score, 2 vs. 3; common odds ratio, 1.7; 95% CI, 1.0 to 2.8; P=0.04). Symptomatic intracerebral hemorrhage occurred in 1% of the patients in each group. CONCLUSIONS: Tenecteplase before thrombectomy was associated with a higher incidence of reperfusion and better functional outcome than alteplase among patients with ischemic stroke treated within 4.5 hours after symptom onset. (Funded by the National Health and Medical Research Council of Australia and others; EXTEND-IA TNK ClinicalTrials.gov number, NCT02388061 .).

Ambulance Clinical Triage for Acute Stroke Treatment: Paramedic Triage Algorithm for Large Vessel Occlusion.

BACKGROUND AND PURPOSE: Clinical triage scales for prehospital recognition of large vessel occlusion (LVO) are limited by low specificity when applied by paramedics. We created the 3-step ambulance clinical triage for acute stroke treatment (ACT-FAST) as the first algorithmic LVO identification tool, designed to improve specificity by recognizing only severe clinical syndromes and optimizing paramedic usability and reliability. METHODS: The ACT-FAST algorithm consists of (1) unilateral arm drift to stretcher <10 seconds, (2) severe language deficit (if right arm is weak) or gaze deviation/hemineglect assessed by simple shoulder tap test (if left arm is weak), and (3) eligibility and stroke mimic screen. ACT-FAST examination steps were retrospectively validated, and then prospectively validated by paramedics transporting culturally and linguistically diverse patients with suspected stroke in the emergency department, for the identification of internal carotid or proximal middle cerebral artery occlusion. The diagnostic performance of the full ACT-FAST algorithm was then validated for patients accepted for thrombectomy. RESULTS: In retrospective (n=565) and prospective paramedic (n=104) validation, ACT-FAST displayed higher overall accuracy and specificity, when compared with existing LVO triage scales. Agreement of ACT-FAST between paramedics and doctors was excellent (κ=0.91; 95% confidence interval, 0.79-1.0). The full ACT-FAST algorithm (n=60) assessed by paramedics showed high overall accuracy (91.7%), sensitivity (85.7%), specificity (93.5%), and positive predictive value (80%) for recognition of endovascular-eligible LVO. CONCLUSIONS: The 3-step ACT-FAST algorithm shows higher specificity and reliability than existing scales for clinical LVO recognition, despite requiring just 2 examination steps. The inclusion of an eligibility step allowed recognition of endovascular-eligible patients with high accuracy. Using a sequential algorithmic approach eliminates scoring confusion and reduces assessment time. Future studies will test whether field application of ACT-FAST by paramedics to bypass suspected patients with LVO directly to endovascular-capable centers can reduce delays to endovascular thrombectomy.

Ischaemic monomelic neuropathy: A rare cause of unilateral foot drop.

Ischaemic neuropathy is a rare phenomenon given the rich arterial collateral supply afforded to peripheral nerves by the vasa nervorum. We report an unusual case of unilateral foot drop secondary to long-segment popliteal artery occlusion. Without expedient vessel imaging and revascularisation of the occluded artery, this reversible cause of neurological deficit would likely have resulted in a poor functional outcome for our patient.

Prehospital idarucizumab prior to intravenous thrombolysis in a mobile stroke unit.

BACKGROUND: Administration of intravenous idarucizumab to reverse dabigatran anticoagulation prior to thrombolysis for patients with acute ischemic stroke has been previously described, but not in the prehospital setting. The speed and predictability of idarucizumab reversal is well suited to prehospital treatment in a mobile stroke unit and allows patients with recent dabigatran intake to access reperfusion therapy. AIMS: To describe feasibility of prehospital idarucizumab administration prior to thrombolysis on the Melbourne mobile stroke unit. METHODS: The Melbourne mobile stroke unit is a specialized stroke ambulance servicing central metropolitan Melbourne, Australia and provides prehospital assessment, scanning and treatment with an integrated CT scanner and multidisciplinary stroke team. All cases were identified through the mobile stroke unit treatment registry since launch in November 2017. RESULTS: Of a total of n = 20 thrombolysis cases in the first 4 months of operation, three patients (15%) received intravenous idarucizumab 5 g for dabigatran reversal prior to thrombolysis. Mean time between idarucizumab administration and thrombolysis was approximately 10 minutes. Two of the three patients were shown to have large vessel occlusion on CTA in the mobile stroke unit and proceeded to endovascular thrombectomy. At 24 hours, only one patient had a small amount of asymptomatic petechial hemorrhage on follow-up imaging. All patients demonstrated substantial neurological recovery and were discharged to inpatient rehabilitation. CONCLUSIONS: Rapid treatment with prehospital administration of idarucizumab prior to thrombolysis using a mobile stroke unit is feasible and facilitates hyperacute treatment.

Outpatient follow-up for patients with rheumatoid arthritis in relation to New Zealand Rheumatology Association guidelines at Dunedin Hospital.

AIM: Current treatment for rheumatoid arthritis (RA) involves the use of various disease-modifying anti-rheumatic drugs (DMARDs) and biologic response agents which require ongoing medical supervision. An audit was undertaken to assess the adequacy of outpatient specialist follow-up for supervision of treatment in patients with RA in the Otago region. METHODS: The Rheumatology Service database was used to assess time between follow-up for the penultimate and last visit to rheumatology outpatient clinic for all patients who made at least two visits between 1 October 2001 and 30 September 2006. Other recorded data included demographic information and clinician expectations for the timing of the next outpatient visit. Comparisons were made between actual follow-up intervals, those indicated by specialists and the follow-up intervals recommended by the New Zealand Rheumatology Association Guidelines. Patients were characterised according to four groups specified in the guidelines: Group A: patients newly started on DMARDs; Group B: patients with some change in disease management: Group C: patient stable on potent medications: Group D: patients stable on less severe medication. RESULTS: According to the guidelines only 40% of patients were followed up within the recommended intervals. Groups A and B (76.9% and 70.6% respectively) had a significantly greater proportion of patients with follow-up at variance to guideline recommendations compared to groups C and D (50% and 45.3% respectively) (p<0.001). There were marked discrepancies between the guideline recommended follow-up intervals and those suggested by the clinicians. Compared with guideline recommendations clinicians advised less frequent follow-up for groups A and B but more frequent for patients in Groups C and D. However, an assessment of the quality of life scores amongst the patients suggested that follow-up was still appropriately targeted to those patients with lower quality of life. CONCLUSION: Discrepancies in follow-up were most marked in the patient groups potentially most at risk of medication-related problems in whom guidelines suggested more intensive monitoring. Additional strategies to promote guideline-based follow-up arrangements may be indicated. Further work should examine the relationships between guideline recommended, physician intended and actual follow-up among rheumatology patients in other regions in order to assess whether modifications should occur to clinician behaviour or guideline content.