This document discusses the evolution of treatments for acute ischemic stroke caused by large vessel occlusion over the past three decades. It describes the development of intravenous thrombolysis using alteplase, including early safety trials, phase 3 efficacy trials, and limitations. It also discusses the emergence of endovascular therapies such as mechanical thrombectomy and the importance of neuroimaging such as CT and CT perfusion in selecting appropriate patients. The role of collateral circulation and a "tissue window" approach are also highlighted.
The document discusses the evolution of treatments for acute ischemic stroke (AIS), including intravenous thrombolysis and mechanical thrombectomy. It summarizes key randomized trials that established the benefits of mechanical thrombectomy. The first-generation trials using early thrombectomy devices did not show benefit, but recent trials using stent retrievers demonstrated significantly improved recanalization rates and superior outcomes for mechanical thrombectomy combined with intravenous thrombolysis compared to intravenous thrombolysis alone in eligible patients presenting within 6 hours of stroke onset. The document concludes that mechanical thrombectomy is now a standard treatment for AIS but remains underutilized.
Recent Advances In Thrombolysis In Stroke PatientAdamya Gupta
1) Recent advances in thrombolysis for stroke patients include extending the treatment window for intravenous rt-PA from 3 hours to 4.5 hours post-stroke onset based on the ECASS III trial results.
2) Intravenous rt-PA is still the standard of care for eligible patients within 4.5 hours, but endovascular thrombectomy is now recommended for eligible patients with a large vessel occlusion up to 24 hours from last known normal.
3) Treatment protocols now focus on a rapid door-to-needle time of 60 minutes or less for intravenous rt-PA and include advances in imaging such as CTA and perfusion imaging to identify patients that may benefit from endovascular thrombectomy.
Mechanical thrombectomy in acute stroke [Autosaved].pptxNeurologyKota
1. The document discusses various techniques for mechanical thrombectomy in acute stroke, including thrombectomy devices, thromboaspiration, and thrombolysis.
2. It summarizes key trials investigating mechanical thrombectomy including DAWN, DEFUSE 3, and a basilar artery occlusion trial. The DAWN and DEFUSE 3 trials showed improved outcomes with thrombectomy plus standard care compared to standard care alone for certain patients.
3. The document outlines considerations for implementing a mechanical thrombectomy program, including patient selection criteria, imaging guidance, procedural timelines, equipment needs, and cost estimates.
Mechanical thrombectomy with stent retrieverDr Vipul Gupta
Vipul Gupta discusses balloon assisted coiling in ruptured cerebral aneurysms and mechanical thrombectomy with stent retrievers. He summarizes several key randomized controlled trials that demonstrated the benefits of endovascular therapy using stent retrievers over standard medical therapy alone for acute ischemic stroke. The trials showed significant improvements in revascularization, clinical outcomes, and mortality. The 2015 AHA/ASA guidelines recommend endovascular therapy with stent retrievers for select patients within 6 hours of stroke onset based on the evidence from these trials. The document also reviews techniques for mechanical thrombectomy and strategies to optimize outcomes.
This document discusses neurosonology and transcranial Doppler ultrasound (TCD). It defines neurosonology as ultrasonic imaging of the brain and neural structures. TCD provides noninvasive, real-time measures of blood flow in the brain's basal arteries. The document outlines the clinical applications of TCD, including monitoring cerebral vasospasm after subarachnoid hemorrhage, detecting intracranial stenosis, assessing acute ischemic stroke, and screening for stroke risk in children with sickle cell disease. TCD is a useful tool for diagnosing and monitoring various cerebrovascular disorders.
1) The document discusses atrial fibrillation (AF), its increasing prevalence, and its association with increased risk of stroke.
2) It reviews stroke risk assessment tools like CHADS2 and CHA2DS2-VASc scores and guidelines for stroke prevention in AF patients using anticoagulation or the newer oral anticoagulants (NOACs).
3) It also discusses left atrial appendage closure with the Watchman device as an alternative for stroke prevention in patients who cannot tolerate long-term anticoagulation. The Watchman trials demonstrated the device's safety and efficacy in reducing stroke risk comparable to warfarin.
Endovascular treatment in acute cerebral ischemianikhilprerana
This document discusses ischemic stroke and endovascular management. It notes that ischemic stroke accounts for 87% of strokes and results in significant disability. It reviews cerebral circulation and the limitations of intravenous tissue plasminogen activator (tPA) therapy. The document then discusses endovascular management techniques in more detail, including intra-arterial thrombolysis, mechanical thrombectomy devices, patient selection, imaging guidance, anesthesia options, reperfusion strategies, and clinical trials of endovascular therapy for middle cerebral artery occlusions.
1) Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. While medical treatments like antithrombotics and statins are recommended, endovascular interventions may be considered for recurrent strokes.
2) Early studies of angioplasty and stenting for ICAD showed high complication rates. The SAMMPRIS trial found stenting plus medical therapy was worse than medical therapy alone. Subsequent studies using strict criteria saw lower complication rates.
3) Current recommendations are for medical management as first-line for ICAD. Endovascular treatments like submaximal angioplasty may be considered for recurrent strokes despite medical therapy, based on the underlying stroke mechanism
The document discusses the evolution of treatments for acute ischemic stroke (AIS), including intravenous thrombolysis and mechanical thrombectomy. It summarizes key randomized trials that established the benefits of mechanical thrombectomy. The first-generation trials using early thrombectomy devices did not show benefit, but recent trials using stent retrievers demonstrated significantly improved recanalization rates and superior outcomes for mechanical thrombectomy combined with intravenous thrombolysis compared to intravenous thrombolysis alone in eligible patients presenting within 6 hours of stroke onset. The document concludes that mechanical thrombectomy is now a standard treatment for AIS but remains underutilized.
Recent Advances In Thrombolysis In Stroke PatientAdamya Gupta
1) Recent advances in thrombolysis for stroke patients include extending the treatment window for intravenous rt-PA from 3 hours to 4.5 hours post-stroke onset based on the ECASS III trial results.
2) Intravenous rt-PA is still the standard of care for eligible patients within 4.5 hours, but endovascular thrombectomy is now recommended for eligible patients with a large vessel occlusion up to 24 hours from last known normal.
3) Treatment protocols now focus on a rapid door-to-needle time of 60 minutes or less for intravenous rt-PA and include advances in imaging such as CTA and perfusion imaging to identify patients that may benefit from endovascular thrombectomy.
Mechanical thrombectomy in acute stroke [Autosaved].pptxNeurologyKota
1. The document discusses various techniques for mechanical thrombectomy in acute stroke, including thrombectomy devices, thromboaspiration, and thrombolysis.
2. It summarizes key trials investigating mechanical thrombectomy including DAWN, DEFUSE 3, and a basilar artery occlusion trial. The DAWN and DEFUSE 3 trials showed improved outcomes with thrombectomy plus standard care compared to standard care alone for certain patients.
3. The document outlines considerations for implementing a mechanical thrombectomy program, including patient selection criteria, imaging guidance, procedural timelines, equipment needs, and cost estimates.
Mechanical thrombectomy with stent retrieverDr Vipul Gupta
Vipul Gupta discusses balloon assisted coiling in ruptured cerebral aneurysms and mechanical thrombectomy with stent retrievers. He summarizes several key randomized controlled trials that demonstrated the benefits of endovascular therapy using stent retrievers over standard medical therapy alone for acute ischemic stroke. The trials showed significant improvements in revascularization, clinical outcomes, and mortality. The 2015 AHA/ASA guidelines recommend endovascular therapy with stent retrievers for select patients within 6 hours of stroke onset based on the evidence from these trials. The document also reviews techniques for mechanical thrombectomy and strategies to optimize outcomes.
This document discusses neurosonology and transcranial Doppler ultrasound (TCD). It defines neurosonology as ultrasonic imaging of the brain and neural structures. TCD provides noninvasive, real-time measures of blood flow in the brain's basal arteries. The document outlines the clinical applications of TCD, including monitoring cerebral vasospasm after subarachnoid hemorrhage, detecting intracranial stenosis, assessing acute ischemic stroke, and screening for stroke risk in children with sickle cell disease. TCD is a useful tool for diagnosing and monitoring various cerebrovascular disorders.
1) The document discusses atrial fibrillation (AF), its increasing prevalence, and its association with increased risk of stroke.
2) It reviews stroke risk assessment tools like CHADS2 and CHA2DS2-VASc scores and guidelines for stroke prevention in AF patients using anticoagulation or the newer oral anticoagulants (NOACs).
3) It also discusses left atrial appendage closure with the Watchman device as an alternative for stroke prevention in patients who cannot tolerate long-term anticoagulation. The Watchman trials demonstrated the device's safety and efficacy in reducing stroke risk comparable to warfarin.
Endovascular treatment in acute cerebral ischemianikhilprerana
This document discusses ischemic stroke and endovascular management. It notes that ischemic stroke accounts for 87% of strokes and results in significant disability. It reviews cerebral circulation and the limitations of intravenous tissue plasminogen activator (tPA) therapy. The document then discusses endovascular management techniques in more detail, including intra-arterial thrombolysis, mechanical thrombectomy devices, patient selection, imaging guidance, anesthesia options, reperfusion strategies, and clinical trials of endovascular therapy for middle cerebral artery occlusions.
1) Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. While medical treatments like antithrombotics and statins are recommended, endovascular interventions may be considered for recurrent strokes.
2) Early studies of angioplasty and stenting for ICAD showed high complication rates. The SAMMPRIS trial found stenting plus medical therapy was worse than medical therapy alone. Subsequent studies using strict criteria saw lower complication rates.
3) Current recommendations are for medical management as first-line for ICAD. Endovascular treatments like submaximal angioplasty may be considered for recurrent strokes despite medical therapy, based on the underlying stroke mechanism
The document discusses ventricular pressure-volume loops and cardiac physiology. It begins by introducing ventricular pressure-volume loops and their use in assessing cardiac function. It then covers the normal cardiac cycle and mechanics, including the isovolumic contraction and relaxation phases. Key concepts like preload, afterload, contractility, compliance, and indices of cardiac function such as ejection fraction, fractional shortening, and Tei index are defined and their clinical significance explained. Older indices assessed by biplane cineangiography are also mentioned.
This document discusses subarachnoid hemorrhage (SAH) and vasospasm, which is a common complication of SAH. It provides an overview of the pathophysiology of SAH and vasospasm, involving factors such as nitric oxide, endothelin-1, and oxidative stress. Current standard therapies aim to prevent rebleeding and improve cerebral blood flow, but have limitations. Emerging therapies are being investigated to more effectively treat and prevent vasospasm.
1. The document summarizes current stroke intervention strategies, including intravenous fibrinolysis (tPA), endovascular interventions like intra-arterial fibrinolysis and mechanical thrombectomy, and decompressive craniotomy.
2. Intravenous tPA is recommended within 3 hours and may be considered within 3-4.5 hours for select patients. Several trials have demonstrated the benefits of intravenous tPA.
3. Intra-arterial fibrinolysis and mechanical thrombectomy are beneficial options for carefully selected patients not eligible for intravenous tPA or who have failed intravenous tPA. Recent trials show improved outcomes with newer mechanical thrombectomy devices compared to older technologies.
This document outlines a stroke management protocol to standardize and expedite treatment for acute ischemic stroke patients. It discusses the importance of minimizing delays from symptom onset to treatment administration given the time-sensitive nature of stroke. The protocol details steps in the pre-hospital, emergency department, and in-hospital phases including rapid neurological assessment, imaging, criteria evaluation, and intravenous thrombolysis administration if eligible, with a goal of completing the entire process within 60 minutes or less. Adhering closely to established guidelines and protocols is emphasized to optimize outcomes for stroke patients.
The document discusses the autonomic nervous system and its disorders. It begins by defining the autonomic nervous system and dividing it into the sympathetic and parasympathetic nervous systems. It then discusses methods of assessing autonomic function, including heart rate variation tests, Valsalva maneuver, quantitative sudomotor axon reflex test, and sympathetic skin response. Next, it covers autonomic disorders like reflex syncope, postural tachycardia syndrome, and functional gastrointestinal disorders. Finally, it discusses autonomic storms and Takotsubo cardiomyopathy, which result from excessive autonomic outflow.
What are anti-coagulants?
What are the difference between antiplatelet, anticoagulants and thrombolytics?
Coagulation cascade
Virchows Triad
Classification of anti-coagulants?
Indications of anti-coagulants?
Mechanism and site of action of different anti-coagulants?
This document discusses anesthesia considerations for carotid endarterectomy. It begins with an overview of the anatomy and indications for the procedure. Important preoperative evaluations are outlined, including risk assessment, neurological examination, and imaging studies. Intraoperative management focuses on hemodynamic stability, cerebral perfusion monitoring via EEG, TCD, jugular bulb oximetry, and stump pressure. General anesthesia and regional anesthesia techniques are compared. Postoperative concerns like wound hematoma, embolism, and hypertension are also reviewed.
The document summarizes the inclusion criteria for two clinical trials: DAWN and DEFUSE 3. Both trials evaluated endovascular thrombectomy for acute ischemic stroke between 6-24 hours after onset. The general criteria for both trials were: age 18 or older, NIHSS score of 10 or higher, signs of acute ischemic stroke, and ability to receive treatment within 6-24 hours. The imaging criteria for both trials required an occlusion of the intracranial ICA or MCA and a clinical-imaging mismatch between the ischemic core and hypoperfused tissue on MRI/CT perfusion. DEFUSE 3 specifically required a core of less than 70ml, mismatch ratio of 1.8 or higher, and mismatch volume of 15
Fourth Universal Definition Of Myocardial Infarction (2018)magdy elmasry
The document discusses the definition and diagnosis of heart attacks. It notes that there has been confusion over how to diagnose heart attacks, but that new 2018 guidelines aim to provide clarity. The guidelines define myocardial infarction based on elevated troponin levels, as well as symptoms and other diagnostic criteria. They distinguish between types of heart attacks based on their underlying causes, such as plaque rupture or an imbalance of oxygen supply and demand. The guidelines emphasize integrating clinical findings, electrocardiograms, imaging, and lab results over time to arrive at an accurate diagnosis.
Imaging based selection of patients for acute stroke treatmentSachin Adukia
1) Several positive randomized controlled trials from 2015 established endovascular therapy (EVT) as effective for recanalization in patients with acute proximal anterior circulation artery occlusion.
2) Non-invasive neuroimaging is needed to exclude intracranial hemorrhage, confirm and localize treatable vessel occlusions, detect irreversible ischemic damage, and characterize salvageable tissue.
3) Recent studies have demonstrated that imaging-based selection of patients for EVT, including analysis of infarct core size, penumbra, and collateral flow, can effectively identify patients likely to benefit from the procedure beyond the 6 hour time window established in earlier trials.
Reversing cardiac remodeling with HFtreatmentPraveen Nagula
1. This document summarizes research on reversing cardiac remodeling through heart failure treatment. It discusses what remodeling is, the history of the term in medical literature, and types of remodeling (pathological vs physiological).
2. Studies show treatments that lead to "reverse remodeling" like sacubitril/valsartan improve outcomes for heart failure patients. Trials like PARADIGM-HF and PROVE-HF found sacubitril/valsartan reduced biomarkers and improved ejection fraction, indicating reverse remodeling.
3. Subgroup analyses in PROVE-HF found consistent reverse remodeling effects in newly diagnosed and ACE-ARB naive patients as well as those not reaching target sacubitril/vals
This document provides an overview of intravenous thrombolysis for acute ischemic stroke, including available agents, safety data, and efficacy studies. It discusses the evidence for alteplase and tenecteplase, including major trials. Tenecteplase is a genetically engineered form of alteplase that requires only intravenous bolus administration. While not FDA-approved for stroke, studies suggest tenecteplase has similar efficacy to alteplase with potentially fewer bleeding complications. Ongoing trials are further evaluating tenecteplase compared to alteplase and standard treatments. The document reviews criteria for use and contraindications of tenecteplase based on acute ischemic stroke studies.
Trans-Cranial Doppler (TCD) is a non-invasive ultrasound technique used to evaluate cerebral blood flow velocities. There are two main types of TCD devices - non-duplex devices which identify arteries "blindly" based on Doppler shift and duplex devices which combine Doppler with B-mode imaging to directly visualize arteries. TCD allows evaluation of intracranial steno-occlusive disease, vasospasm, aneurysms, and other conditions. It can detect elevated velocities indicative of stenosis but has limitations including operator dependence and inability to image distal arteries. TCD is useful for monitoring conditions like sickle cell disease where elevated velocities increase stroke risk.
This document discusses the management of seizures related to stroke. It notes that the incidence of seizures is about 9% after stroke, with higher rates for hemorrhagic versus ischemic strokes. Seizures are mainly related to occlusive vascular disease and large cortical infarcts increase risk, especially those in the temporal-parietal regions. Late-onset seizures between 6 months and 2 years post-stroke are most common and have a high recurrence rate. Treatment involves anti-epileptic drugs like carbamazepine or lamotrigine. Seizures after stroke are harmful and worsen patient outcomes and disability.
Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Ade Wijaya
Cerebral vasospasm is narrowing of the cerebral arteries that occurs 3-14 days after aneurysmal subarachnoid hemorrhage. It can lead to delayed cerebral ischemia and poor outcomes. Risk factors include severe initial bleeding on CT scan and cigarette smoking. Diagnosis involves clinical exams, transcranial Doppler, CT/MR angiography and DSA. Treatment focuses on preventing vasospasm through hemodynamic therapy like hyperdynamic therapy and managing it with calcium channel blockers or angioplasty if severe.
1) Natriuretic peptides like BNP and NT-proBNP are the most extensively studied and used biomarkers in heart failure. They are useful for diagnosis, assessing prognosis, and monitoring response to treatment.
2) Other biomarkers like troponins, ST2, galectin-3, and inflammatory markers can provide additional prognostic information beyond natriuretic peptides.
3) Biomarkers reflect different pathophysiological processes in heart failure like myocyte injury, stress, remodeling, neurohormonal activation, and inflammation. Used together, they can improve risk stratification and guidance of therapy.
This document summarizes various thrombolytic agents and treatment strategies for acute ischemic stroke. It discusses that alteplase is currently the only approved thrombolytic, but tenecteplase is being studied as a potential alternative due to easier administration. Ongoing trials are comparing tenecteplase to alteplase. Other emerging strategies discussed include intra-arterial thrombolysis, mechanical thrombectomy, and the use of mobile stroke units.
The document summarizes several key updates to the 10th edition of the ATLS guidelines. Some notable changes include restricting initial fluid resuscitation to 1 L, emphasizing drug-assisted intubation over rapid sequence intubation, recommending early use of blood products and tranexamic acid for shock management, and introducing algorithms for traumatic cardiac arrest and pelvic fracture hemorrhage. The guidelines also provide new recommendations for several areas like needle thoracocentesis location, head trauma anticoagulation reversal, and avoiding unnecessary CT scans during transfer to definitive care.
The document discusses ventricular pressure-volume loops and cardiac physiology. It begins by introducing ventricular pressure-volume loops and their use in assessing cardiac function. It then covers the normal cardiac cycle and mechanics, including the isovolumic contraction and relaxation phases. Key concepts like preload, afterload, contractility, compliance, and indices of cardiac function such as ejection fraction, fractional shortening, and Tei index are defined and their clinical significance explained. Older indices assessed by biplane cineangiography are also mentioned.
This document discusses subarachnoid hemorrhage (SAH) and vasospasm, which is a common complication of SAH. It provides an overview of the pathophysiology of SAH and vasospasm, involving factors such as nitric oxide, endothelin-1, and oxidative stress. Current standard therapies aim to prevent rebleeding and improve cerebral blood flow, but have limitations. Emerging therapies are being investigated to more effectively treat and prevent vasospasm.
1. The document summarizes current stroke intervention strategies, including intravenous fibrinolysis (tPA), endovascular interventions like intra-arterial fibrinolysis and mechanical thrombectomy, and decompressive craniotomy.
2. Intravenous tPA is recommended within 3 hours and may be considered within 3-4.5 hours for select patients. Several trials have demonstrated the benefits of intravenous tPA.
3. Intra-arterial fibrinolysis and mechanical thrombectomy are beneficial options for carefully selected patients not eligible for intravenous tPA or who have failed intravenous tPA. Recent trials show improved outcomes with newer mechanical thrombectomy devices compared to older technologies.
This document outlines a stroke management protocol to standardize and expedite treatment for acute ischemic stroke patients. It discusses the importance of minimizing delays from symptom onset to treatment administration given the time-sensitive nature of stroke. The protocol details steps in the pre-hospital, emergency department, and in-hospital phases including rapid neurological assessment, imaging, criteria evaluation, and intravenous thrombolysis administration if eligible, with a goal of completing the entire process within 60 minutes or less. Adhering closely to established guidelines and protocols is emphasized to optimize outcomes for stroke patients.
The document discusses the autonomic nervous system and its disorders. It begins by defining the autonomic nervous system and dividing it into the sympathetic and parasympathetic nervous systems. It then discusses methods of assessing autonomic function, including heart rate variation tests, Valsalva maneuver, quantitative sudomotor axon reflex test, and sympathetic skin response. Next, it covers autonomic disorders like reflex syncope, postural tachycardia syndrome, and functional gastrointestinal disorders. Finally, it discusses autonomic storms and Takotsubo cardiomyopathy, which result from excessive autonomic outflow.
What are anti-coagulants?
What are the difference between antiplatelet, anticoagulants and thrombolytics?
Coagulation cascade
Virchows Triad
Classification of anti-coagulants?
Indications of anti-coagulants?
Mechanism and site of action of different anti-coagulants?
This document discusses anesthesia considerations for carotid endarterectomy. It begins with an overview of the anatomy and indications for the procedure. Important preoperative evaluations are outlined, including risk assessment, neurological examination, and imaging studies. Intraoperative management focuses on hemodynamic stability, cerebral perfusion monitoring via EEG, TCD, jugular bulb oximetry, and stump pressure. General anesthesia and regional anesthesia techniques are compared. Postoperative concerns like wound hematoma, embolism, and hypertension are also reviewed.
The document summarizes the inclusion criteria for two clinical trials: DAWN and DEFUSE 3. Both trials evaluated endovascular thrombectomy for acute ischemic stroke between 6-24 hours after onset. The general criteria for both trials were: age 18 or older, NIHSS score of 10 or higher, signs of acute ischemic stroke, and ability to receive treatment within 6-24 hours. The imaging criteria for both trials required an occlusion of the intracranial ICA or MCA and a clinical-imaging mismatch between the ischemic core and hypoperfused tissue on MRI/CT perfusion. DEFUSE 3 specifically required a core of less than 70ml, mismatch ratio of 1.8 or higher, and mismatch volume of 15
Fourth Universal Definition Of Myocardial Infarction (2018)magdy elmasry
The document discusses the definition and diagnosis of heart attacks. It notes that there has been confusion over how to diagnose heart attacks, but that new 2018 guidelines aim to provide clarity. The guidelines define myocardial infarction based on elevated troponin levels, as well as symptoms and other diagnostic criteria. They distinguish between types of heart attacks based on their underlying causes, such as plaque rupture or an imbalance of oxygen supply and demand. The guidelines emphasize integrating clinical findings, electrocardiograms, imaging, and lab results over time to arrive at an accurate diagnosis.
Imaging based selection of patients for acute stroke treatmentSachin Adukia
1) Several positive randomized controlled trials from 2015 established endovascular therapy (EVT) as effective for recanalization in patients with acute proximal anterior circulation artery occlusion.
2) Non-invasive neuroimaging is needed to exclude intracranial hemorrhage, confirm and localize treatable vessel occlusions, detect irreversible ischemic damage, and characterize salvageable tissue.
3) Recent studies have demonstrated that imaging-based selection of patients for EVT, including analysis of infarct core size, penumbra, and collateral flow, can effectively identify patients likely to benefit from the procedure beyond the 6 hour time window established in earlier trials.
Reversing cardiac remodeling with HFtreatmentPraveen Nagula
1. This document summarizes research on reversing cardiac remodeling through heart failure treatment. It discusses what remodeling is, the history of the term in medical literature, and types of remodeling (pathological vs physiological).
2. Studies show treatments that lead to "reverse remodeling" like sacubitril/valsartan improve outcomes for heart failure patients. Trials like PARADIGM-HF and PROVE-HF found sacubitril/valsartan reduced biomarkers and improved ejection fraction, indicating reverse remodeling.
3. Subgroup analyses in PROVE-HF found consistent reverse remodeling effects in newly diagnosed and ACE-ARB naive patients as well as those not reaching target sacubitril/vals
This document provides an overview of intravenous thrombolysis for acute ischemic stroke, including available agents, safety data, and efficacy studies. It discusses the evidence for alteplase and tenecteplase, including major trials. Tenecteplase is a genetically engineered form of alteplase that requires only intravenous bolus administration. While not FDA-approved for stroke, studies suggest tenecteplase has similar efficacy to alteplase with potentially fewer bleeding complications. Ongoing trials are further evaluating tenecteplase compared to alteplase and standard treatments. The document reviews criteria for use and contraindications of tenecteplase based on acute ischemic stroke studies.
Trans-Cranial Doppler (TCD) is a non-invasive ultrasound technique used to evaluate cerebral blood flow velocities. There are two main types of TCD devices - non-duplex devices which identify arteries "blindly" based on Doppler shift and duplex devices which combine Doppler with B-mode imaging to directly visualize arteries. TCD allows evaluation of intracranial steno-occlusive disease, vasospasm, aneurysms, and other conditions. It can detect elevated velocities indicative of stenosis but has limitations including operator dependence and inability to image distal arteries. TCD is useful for monitoring conditions like sickle cell disease where elevated velocities increase stroke risk.
This document discusses the management of seizures related to stroke. It notes that the incidence of seizures is about 9% after stroke, with higher rates for hemorrhagic versus ischemic strokes. Seizures are mainly related to occlusive vascular disease and large cortical infarcts increase risk, especially those in the temporal-parietal regions. Late-onset seizures between 6 months and 2 years post-stroke are most common and have a high recurrence rate. Treatment involves anti-epileptic drugs like carbamazepine or lamotrigine. Seizures after stroke are harmful and worsen patient outcomes and disability.
Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Ade Wijaya
Cerebral vasospasm is narrowing of the cerebral arteries that occurs 3-14 days after aneurysmal subarachnoid hemorrhage. It can lead to delayed cerebral ischemia and poor outcomes. Risk factors include severe initial bleeding on CT scan and cigarette smoking. Diagnosis involves clinical exams, transcranial Doppler, CT/MR angiography and DSA. Treatment focuses on preventing vasospasm through hemodynamic therapy like hyperdynamic therapy and managing it with calcium channel blockers or angioplasty if severe.
1) Natriuretic peptides like BNP and NT-proBNP are the most extensively studied and used biomarkers in heart failure. They are useful for diagnosis, assessing prognosis, and monitoring response to treatment.
2) Other biomarkers like troponins, ST2, galectin-3, and inflammatory markers can provide additional prognostic information beyond natriuretic peptides.
3) Biomarkers reflect different pathophysiological processes in heart failure like myocyte injury, stress, remodeling, neurohormonal activation, and inflammation. Used together, they can improve risk stratification and guidance of therapy.
This document summarizes various thrombolytic agents and treatment strategies for acute ischemic stroke. It discusses that alteplase is currently the only approved thrombolytic, but tenecteplase is being studied as a potential alternative due to easier administration. Ongoing trials are comparing tenecteplase to alteplase. Other emerging strategies discussed include intra-arterial thrombolysis, mechanical thrombectomy, and the use of mobile stroke units.
The document summarizes several key updates to the 10th edition of the ATLS guidelines. Some notable changes include restricting initial fluid resuscitation to 1 L, emphasizing drug-assisted intubation over rapid sequence intubation, recommending early use of blood products and tranexamic acid for shock management, and introducing algorithms for traumatic cardiac arrest and pelvic fracture hemorrhage. The guidelines also provide new recommendations for several areas like needle thoracocentesis location, head trauma anticoagulation reversal, and avoiding unnecessary CT scans during transfer to definitive care.
The document provides an overview of updates to the 10th edition of the Advanced Trauma Life Support (ATLS) guidelines. Key changes include a more judicious approach to fluid resuscitation, a focus on early use of blood products and management of coagulopathy, revisions to guidelines for needle thoracocentesis and management of tension pneumothorax, and emphasis on avoiding unnecessary imaging and procedures at primary hospitals to expedite transfer to definitive care facilities. The trauma team approach is highlighted throughout the new guidelines.
This document summarizes the results of the ENCHANTED clinical trial which compared low-dose (0.6 mg/kg) intravenous alteplase to standard-dose (0.9 mg/kg) for acute ischemic stroke. The trial found that low-dose alteplase was not inferior to standard-dose for functional outcomes at 90 days, carried a lower risk of symptomatic intracerebral hemorrhage, and showed a trend toward lower mortality. Specifically, major hemorrhage occurred in 1.0% of low-dose patients versus 2.1% of standard-dose patients. Mortality was also lower in the low-dose group at 7 days. The study demonstrates that a lower dose of
This document provides information about stroke, including:
1. Stroke is caused by a lack of oxygen to the brain from blocked or ruptured arteries, and is a leading cause of death and disability in the US and worldwide.
2. The two main types of stroke are ischemic (87% of cases) and hemorrhagic (13% of cases).
3. Signs of stroke include sudden weakness, confusion, trouble speaking, vision issues, loss of balance, and severe headaches with no known cause. Early treatment leads to better outcomes.
- Stroke is a major cause of death and disability in the US, with nearly 800,000 new cases each year.
- Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) can help restore blood flow for acute ischemic stroke if administered within 3-4.5 hours of symptom onset.
- Several clinical trials showed that rt-PA administered within 3 hours of symptoms increased the likelihood of minimal or no disability compared to placebo, though it also increased the risk of intracranial hemorrhage.
Approach to Management of Fever & Sepsis (2) copy.pptxHarryArwin1
1) Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. It can be identified at the bedside using qSOFA, which is positive if a patient has at least two of respiratory rate above 22, altered mentation, or systolic blood pressure of 100 or less.
2) Initial management of sepsis involves administering antibiotics within 1 hour, giving IV fluids aggressively, and completing other resuscitation bundles like the Sepsis Six within 3 hours to support vital organ function.
3) Beyond initial resuscitation, source control, additional organ support, and adjustment of care based on clinical response are important for managing sepsis.
Fibrinolytic treatment of acute myocardial infarction by tenecteplasedesktoppc
Tenecteplase is a fibrin-specific thrombolytic agent used to treat ST-elevation myocardial infarction. It is a modified form of tissue plasminogen activator (tPA) developed to have a longer half-life than other tPAs. Tenecteplase works by activating fibrin-bound plasminogen to plasmin, specifically dissolving blood clots containing fibrin. It is administered as a single intravenous bolus within 10 minutes of diagnosis of a STEMI. Guidelines recommend tenecteplase or other fibrin-specific agents for reperfusion when primary PCI is not available within 120 minutes.
an updated account on management of TIA, Ischemic and hemorrhagic stroke in Sri Lanka. This is based on American Stroke Association and NICE guidelines.
Guidelines for management of acute strokesankalpgmc8
This document provides an overview of stroke types, pathophysiology, investigations, and management guidelines. It discusses the three main types of stroke: ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage. For ischemic stroke, it describes the ischemic core and penumbra. It outlines the emergency evaluation of acute ischemic stroke including vital signs, blood tests, imaging, and scales like the NIH Stroke Scale. Management strategies discussed include thrombolysis, antiplatelet/anticoagulation drugs, neuroprotective agents, and surgical interventions. Complications like cerebral edema and their management are also summarized.
This document summarizes stroke treatment procedures at Beaumont Hospital from 2010-2013. It finds that 107 patients underwent mechanical thrombectomy for ischemic stroke, with 12 receiving general anesthesia. Risk factors for the GA patients included hypertension, smoking, and atrial fibrillation. Most strokes involved the middle cerebral or internal carotid arteries. Complications from the procedure included hemorrhage and low MRS scores at 3 months for GA patients. The need for GA may increase over time, requiring improved protocols to ensure safer anesthesia for high-risk stroke patients undergoing emergent clot retrieval.
Actilyse_E2E_IV thrombolysis in high-risk AIS patients_V2.pptxRahulJankar4
This document discusses intravenous thrombolysis with alteplase in high-risk acute ischemic stroke patients. It begins by reviewing the evidence from major clinical trials that established alteplase as the standard of care for stroke thrombolysis within 4.5 hours of symptom onset. It then examines the evidence for thrombolysis in several high-risk patient profiles, including those with cardioembolic stroke, recent myocardial infarction, baseline hyperglycemia, and hypertension. For hypertension, it discusses management to control blood pressure before and after thrombolysis to reduce hemorrhagic risks while maintaining cerebral perfusion. The document concludes that alteplase is effective and safe for thrombolysis in acute ischemic stroke patients with baseline blood
This document discusses the treatment of pulmonary embolism (PE), specifically addressing the debate around treating massive versus submassive PE with thrombolysis. It presents three case studies of patients treated with thrombolysis for suspected PE. It then defines massive and submassive PE and reviews the potential pros and cons of systemic thrombolysis for submassive PE. Guidelines from studies and trials are presented on administering thrombolytics, anticoagulation treatment, and risk-adjusted management strategies for acute PE. The document concludes that the decision to treat with thrombolysis is difficult and should involve input from seniors/consultants, stakeholders, and a multidisciplinary discussion weighing the risks and benefits of thrombolysis for each
1. Thrombolysis using intravenous rt-PA within 3-4.5 hours of stroke onset is the primary reperfusion therapy approved by the FDA.
2. Other reperfusion therapies include intra-arterial thrombolysis, mechanical thrombectomy devices, sonothrombolysis, laser thrombolysis, and percutaneous angioplasty.
3. Neuroprotective therapies aim to reduce excitatory neurotransmitters, reperfusion injury, and neuronal cell death through mechanisms such as decreasing calcium influx and free radical production.
The document provides an overview of managing patients with bleeding disorders. It discusses hemostasis, common lab tests used to evaluate clotting mechanisms, and causes of bleeding disorders including platelet disorders and factor deficiencies. Guidelines are presented for identifying patients with bleeding disorders based on their history. Techniques to maintain hemostasis during surgery include using a harmonic scalpel. The document also reviews recommendations for treating patients taking antiplatelet drugs, anticoagulants, or fibrinolytic drugs and discusses hemophilia and conclusions.
This document summarizes the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial, which aimed to determine if rapidly lowering systolic blood pressure to ≤140 mm Hg (intensive treatment) versus ≤180 mm Hg (standard treatment) in patients with intracerebral hemorrhage treated within 4.5 hours of symptom onset reduces death and disability. The trial randomized patients to 24 hours of intravenous nicardipine to achieve the assigned blood pressure target. The primary outcome was death or disability (modified Rankin score 4-6) at 3 months. Secondary outcomes included hematoma expansion and quality of life measures.
1) Cardiogenic shock is defined as hypotension, hypoperfusion, and elevated filling pressures caused by depressed left ventricular function following myocardial injury. Mortality from cardiogenic shock remains high at 50-70%.
2) Risk factors for cardiogenic shock include age over 65, female gender, large myocardial infarction, anterior infarction location, prior infarction history, diabetes, and hypertension. Post-mortem studies show extensive myocardial damage in patients who die from cardiogenic shock.
3) Early revascularization through percutaneous coronary intervention or coronary artery bypass grafting may improve survival outcomes for cardiogenic shock, especially in patients under age 75, according to the landmark SHOCK trial. Adjunctive therapies including intra
1. The document discusses several studies that have evaluated the use of thromboelastography (TEG) or thromboelastometry (ROTEM) to guide blood product transfusion in patients undergoing cardiac surgery or with massive bleeding.
2. The studies found that TEG/ROTEM-guided transfusion protocols may reduce the use of blood products such as fresh frozen plasma, platelets, and total units transfused compared to usual care. However, the evidence is still weak to moderate and did not show significant effects on mortality or other clinical outcomes.
3. Confounding factors between studies include differences in the time points for TEG/ROTEM monitoring, transfusion triggers, and
Similar to revasularisation of acute stroke.pptx (20)
I. Pain pathways involve nociceptors detecting damaging stimuli and transmitting signals along primary afferent neurons to the dorsal horn. Signals then project up the spinal cord and through ascending tracts to various brain regions for processing. Descending pathways from the brain modulate pain transmission.
II. The document outlines the history of pain theories, definitions of pain terminology, embryological development of pain pathways, types of pain, and components of the pain pathway including nociceptors, neurons, and brain regions involved in perception.
III. Key aspects of acute and chronic pain are distinguished. The gate control theory proposes that non-painful stimuli can inhibit pain transmission at the dorsal horn. Overall the document provides a comprehensive overview of
This document discusses medical therapies for Parkinson's disease. It begins by describing the pathophysiology of Parkinson's, noting that dopamine neuron loss in the substantia nigra leads to neuronal imbalance and motor symptoms. The document then reviews various pharmacological treatments including levodopa, dopamine agonists, NMDA receptor antagonists, MAO-B inhibitors, and COMT inhibitors. For each class of drug, it discusses chemistry, mechanisms of action, pharmacokinetics, indications, adverse effects, drug interactions and contraindications. Surgical therapies are also briefly mentioned.
Cerebral ischemia occurs when blood flow to the brain is reduced, limiting oxygen and glucose delivery. This can lead to reversible brain dysfunction or irreversible infarction. The core of an infarct sees blood flow drop below 10ml/100g/min, causing necrosis. The ischemic penumbra has blood flow of 10-20ml/100g/min, where cells face apoptosis if flow is not restored. Autoregulation and collateral circulation help maintain blood flow, but below 20ml/100g/min for over 3 minutes causes energy failure and cell damage from free radicals and acidosis. Early reperfusion can salvage penumbral tissue at risk of progression to infarction.
The document summarizes the physiology of muscle contraction. It begins with a brief history of muscle research and discoveries. It then discusses the structure and organization of skeletal muscle including sarcomeres, myofilaments, regulatory proteins, cytoskeletal proteins, innervation, and motor units. The document explains the process of muscle contraction including excitation, excitation-contraction coupling, crossbridge cycling, and relaxation. It provides diagrams to illustrate these concepts. In summary, the document provides a comprehensive overview of the anatomy, physiology, and molecular mechanisms underlying skeletal muscle contraction.
The hypothalamus controls many essential functions through its connections with the pituitary gland and autonomic nervous system. It regulates homeostasis, hormone production and secretion, circadian rhythms, temperature, hunger and thirst, sleep cycles, emotions, and reproductive functions. The hypothalamus is located below the thalamus and forms part of the walls and floor of the third ventricle. It is divided into four levels - preoptic, supraoptic, tuberal, and mammillary - which contain nuclei that integrate homeostatic processes and regulate the endocrine and autonomic nervous systems.
This document discusses the dystrophin glycoprotein complex (DGC) and staining of muscle tissue. It begins with an introduction to muscle contraction and the role of the DGC in providing a mechanical link from the cytoskeleton to the extracellular matrix. It then describes the various proteins that make up the DGC, including dystrophin, dystroglycan, sarcoglycans, dystrobrevins, syntrophins, sarcospan, caveolin-3, and nitric oxide synthase. It details the structure and functions of these proteins. Finally, it discusses techniques for staining muscle tissue, including hematoxylin and eosin staining and NADH staining, which can identify different muscle fiber types.
Skeletal muscle is composed of bundles of long cylindrical multinucleated cells called muscle fibers. Muscle fibers contain protein filaments of actin and myosin that slide past each other, causing muscle contraction. There are three types of muscle fibers - slow twitch, fast twitch fatigue-resistant, and fast twitch fatigable. Muscle contraction occurs via the sliding filament model, where cross bridges form between actin and myosin filaments, shortening the muscle. ATP provides energy for the cross bridge cycling that causes contraction.
1. The document provides guidance on evaluating and diagnosing anemia in children. It outlines key signs, symptoms, and pointers that suggest a child may have anemia.
2. Laboratory tests that can help determine the severity and type of anemia include complete blood count, hematocrit, reticulocyte count, blood indices, and peripheral smear.
3. A thorough history, physical exam, and lab work are needed to assess if a child is anemic, determine the severity, and identify the potential cause and type, such as blood loss, decreased red blood cell production, or increased red blood cell destruction.
This document provides information on arthropod vector borne diseases. It discusses key topics such as the definition of arthropods and vectors. It also outlines the different modes of disease transmission by vectors including direct contact, mechanical transmission, and various types of biological transmission. Several important vector-borne diseases are described in detail, including the vectors that transmit them, their signs and symptoms, diagnosis, treatment, and prevention. Diseases covered include malaria, lymphatic filariasis, Japanese encephalitis, dengue, yellow fever, and more.
This document discusses the guidelines for setting up and operating newborn care units at various levels of healthcare facilities in India. It describes the objectives and services provided by Newborn Care Corners (NBCC), Newborn Stabilization Units (NBSU), and Special Newborn Care Units (SNCU). It outlines the necessary infrastructure, equipment, staffing, and training required for proper functioning of these units. The document emphasizes the importance of infection control, documentation, cooperation between obstetric and neonatal staff, and providing standardized care according to the unit's designated level of care.
This document summarizes the early development of the heart from formation of the cardiac tube to septation and looping. It discusses:
- How the cardiac progenitor cells form paired tubes that fuse to form the primitive heart tube by 22 days.
- The lineages that give rise to the left and right ventricles.
- How signaling molecules regulate morphogenesis and migration of cells.
- The process of cardiac looping around 22-24 days which brings the ventricles into left/right orientation.
- Septation of the atria, atrioventricular canal and ventricles between 26-30 days which divides the heart into four chambers.
This document provides an overview of hydrocephalus. It defines hydrocephalus as an abnormal enlargement of the head due to impaired circulation or absorption of cerebrospinal fluid. Hydrocephalus can be communicating or obstructive. It discusses the history, causes, types, symptoms, investigations and management of hydrocephalus. For management, it describes medical options to decrease CSF production or increase absorption. It also discusses various surgical procedures like shunt placement and endoscopic third ventriculostomy to divert CSF and bypass obstructions. Complications of shunt surgery like infections, mechanical issues and overdrainage are also summarized.
This document discusses various types of birth injuries that can occur during labor and delivery. It begins by defining birth injuries and noting their prevalence. It then covers predisposing risk factors and provides a classification system for birth injuries involving soft tissue, the head/neck, facial structures, nerves, fractures, and internal organs. The remainder of the document delves into specific injury types like brachial plexus palsy, skull fractures, retinal hemorrhages, and clavicle fractures, describing their causes, signs/symptoms, diagnosis, and management.
This document provides information about snake bites in India. It notes that India has an estimated 200,000 snake bites per year resulting in 35,000-50,000 deaths. The four most dangerous venomous snakes in India are the common cobra, Russell's viper, saw-scaled viper, and common krait. Snake venom contains various toxins that can cause neurotoxic, hemotoxic, or cytotoxic effects depending on the species. Proper first aid includes reassuring the victim, immobilizing the bitten area, seeking immediate medical care, and informing doctors of any symptoms. Antivenom is the primary treatment and works by neutralizing free venom, with lyophilized antivenom administered via intravenous injection or infusion.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
low birth weight presentation. Low birth weight (LBW) infant is defined as the one whose birth weight is less than 2500g irrespective of their gestational age. Premature birth and low birth weight(LBW) is still a serious problem in newborn. Causing high morbidity and mortality rate worldwide. The nursing care provide to low birth weight babies is crucial in promoting their overall health and development. Through careful assessment, diagnosis,, planning, and evaluation plays a vital role in ensuring these vulnerable infants receive the specialize care they need. In India every third of the infant weight less than 2500g.
Birth period, socioeconomical status, nutritional and intrauterine environment are the factors influencing low birth weight
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
2. Introduction
• Ischemic stroke due to large artery occlusion (LAO)
predominates as a cause of disability, institutionalization, and
costs to healthcare and society.
• Therapies have changed the outcome of many patients with
acute ischemic stroke, preventing death and incapacity.
3. Evolution of Acute Ischemic Stroke (AIS) Care
• The past three decades have seen a revolution in the treatment of acute
ischemic stroke caused by large vessel occlusion (LVO).
4. In-hospital acute stroke pathway
Patient arrives without emergency
services team
Emergency department
Imaging(CT scan/MRI)
Eligible
for thrombolysis?
Triage nurse training
Identification assessment
(FAST/ASA)
Notify ED doctor
Stabilise patient
Basic investigations, ECG and lab
tests
Establish time of onset
Severity assessment (NIHSS
score)
Differential diagnosis
Notify stroke team (stroke call)
Request imaging
Referral to stroke unit
Stroke Unit
"TIME IS
BRAIN"
"TIME IS
BRAIN"
8. History of Thrombolytics
• The first thrombolytic activity was found by Tillet and Garner in 1933 in a
substance produced by group A beta-hemolytic streptococci.
• The substance was responsible for the clot dissolution was initially named
fibrinolysin, but the name was later changed to streptokinase .
• Fletcher et al. were the first to deliver IV streptokinase to human patients with
acute MI in 1958.
• During the 1980s, through recombinant technology, multiple second and third
generation lytics were developed.
• Second generation agent is alteplase (recombinant tissue plasminogen activator
[rt-PA]).
• Third generation thrombolytics Tenecteplase and reteplase had their chemical
structure slightly altered to increase fibrin specificity and to increase half-life.
9. Plasminogen activators
Endogenous:
• Tissue type plasminogen activator
(endothelial cells)
• Urokinase ( synthesized by renal and
malignant cells)
Novel :
• Microplasmin (recombinant form
microplasminogen)
Exogenous :
• Streptokinase (β hemolytic
streptococci)
• Anisoylated plasminogen
streptokinase activator complex
• Staphylokinase(from staphylococcus
aureus)
• Ancrod (venom from pit viper)
10. • Alteplase is a purified glycoprotein
• 527 amino acids
• synthesised from the complementary
DNA of natural human tissue-type
plasminogen activator found in
human melanoma cells.
• five structural components : a
protease, epidermal growth factor
(EGF) and two kringle domains
(Figure 3).
• The lysine binding sites of alteplase
are on the kringle 2 domain .
11. • Tenecteplase (TNK-tPA) is a third
generation point mutation tissue
plasminogen activator created by
recombinant DNA technology from a
mammalian cell line.
• 527 amino acid glycoprotein.
• Tenecteplase has modifications at
three sites of the protein structure on
the complementary DNA template
that differentiate TNK from Alteplase,
• substitution of threonine 103 with
asparagine
• substitution of asparagine 117 with
glutamine
• tetra-alanine substitution at amino
acids 296-299 in the protease domain
12.
13. Thrombolysis for Cerebral Infarction: Early
Development
• Initial studies of thrombolysis in humans began in the late 1950s, but had
major limitations.
• Initial studies took place prior to the advent of computed tomography
(CT)
• Cerebrospinal fluid evaluation was performed to rule out hemorrhage.
• Medications initially tested were plasmin, strepto kinase, and urokinase.
• After the advent of CT in the 1980s, improved outcomes were noted in
urokinase- or streptokinase-treated patients.
• In1980s with the development of rt-PA pre clinical stroke evaluation using
an embolic model was performed by Zivin et al.
• Benefits seen with rt-PA were no anaphylactic-type reactions, no
antibodies were formed to rt-PA, complication of ICH less compared to
other thrombolytics.
14. Early Safety and Dose-Finding Trials in Stroke
• Phase I dose-escalation clinical trials using alteplase (rt-PA) were carried
out in the late 1980s in 2 parts: <90 minutes (74), 91 to 180 minutes(20)
• Doses of alteplase ranged from 0.35 to 1.08 mg/kg.
• Only 1 intracranial hematoma occurred among 64 patients received (1.5%)
who 0.85 mg/kg
• Higher doses 0.95 mg/kg were statistically associated with symptomatic
intracranial hemorrhages.
• Results of these 2 phase I studies led to the eventual 0.9 mg/kg alteplase
dose that is currently being used.
• del Zoppo et al. contributed important IV t-PA dose rate escalation
information in 139 patients who had recanalization monitored by a
conventional angiogram.
15. Review of Phase 3 Efficacy Trials
• Three major phase III clinical trials of alteplase were conducted in the 1990.
1) European Cooperative Acute Stroke Study (ECASS),
2) ECASS-II
3) National Institute of Neurological Disorder and Stroke (NINDS) rt- PA Stroke
trial
16. ECASS
• This study randomized 620 patients to placebo vs 1.1 mg/kg
alteplase within 6 h of symptom onset .
• More than 80% of the patients were enrolled within the 3- to
6-h window
• study did not reveal a significant difference between groups.
17. NINDS rt-PA study
• patients with a placebo vs 0.9 mg/kg of alteplase within 3 h of symptom onset.
• Half the patients treated with in 90 min.
• Study conducted in two parts.
• Part 1 was a phase 2b study of 291 patients having a primary endpoint 4-point
improvement of NIHSS at 24-h.
• part 2, a phase 3 study of 333 patients having a secondary endpoint of a 3-
month outcome.
• 4 different outcome measures (NIHSS, Barthel Index, modified Rankin scale
and the Glasgow outcome scale)
• greater rates of symptomatic intracerebral hemorrhage in alteplase group.
• Number needed to treat was 8 and the number needed to harm (causing a
symptomatic hemorrhage) was 17.
• Results of the NINDS trials led to 1996 Food and Drug Administration approval
of alteplase for acute ischemic stroke.
18. ECASS-II
• A second European trial studied the same t-PA dose (0.9 mg/kg) and
completed in 1998 .
• In contrast to the NINDS t-PA study, ECASS-II continued to study the 0 to
6-h treatment window.
• Again, the majority of patients were treated in the 3- to 6-h time frame
and no statistically significant difference was found between groups
19. ECASS-III and EPITHET
• The apparent treatment effect between 3- and 4.5-h was formally tested
in these studies.
• Total of 821
• NIHSS score was 9 in the t-PA group and 10 in the placebo
• More patients had a favorable outcome with alteplase than with placebo .
• The incidence of symptomatic intracerebral hemorrhage (sICH) was higher
with alteplase than with placebo (mortality did not differ).
20. IV TPA TRIALS
6 major randomized placebo controlled trials
Alteplase Thrombolysis for Acute Non Interventional Therapy in Ischemic
stroke(ATLANTIS) I and II
European Cooperative Acute Stroke Study(ECASS) I and II
NINDS I and II
• 2775 Pts treated with IV rtPA or a placebo within 6hrs of onset
• Confined the benefit up to 3hrs
• ECASS III subsequently confirmed benefit of IV tPA in a 3 to 4.5hr window
21.
22.
23. Management of Blood Pressure in Ischemic stroke
• In acute ischemic stroke, parenteral antihypertensive medication should be
recommended only if there is a hypertensive emergency.
o hypertensive encephalopathy
o Malignant Hypertension
o hypertensive cardiac failure/myocardial infarction
o aortic dissection
o pre- eclampsia/eclampsia
Antihypertensive medication should be withheld in ischemic stroke patients unless
systolic blood pressure/diastolic blood pressure(SBP/DBP) >220/120 mmHg or the mean
arterial blood pressure (MAP) is >120mmHg. Lowering by 15% during the first 24 hours is
recommended.
Except in hypertensive emergency, lowering of blood pressure should be slow and with
use of oral medications.
Sublingual use of antihypertensive is not recommended.
Blood pressure reduction to 185/110 mmHg or lower should be considered in people who
are candidates for thrombolysis.
24. Pre-Thrombolysis
• If BP is >185/110 mm of Hg, Inj. labetolol 10-20mg I.V. should be given over 1-
2min and may be repeated every 10 min to a maximum dose of 300mg or
labetolol infusion can be started at 1 -8mg/min.
• If labetolol is not available, nitroglycerin infusion at 5μg/min or nicardipine
infusion at 5mg/hour is an alternative to labetolol.
• Aim is to continue treatment till target BP <185/110 mm Hg is achieved.
Post-Thrombolysis
• BP should be monitored every 15 min for 2 hours, then every 30min for next 6
hours and finally every hour for next 16 hours.
• BP goal is <180/105 mmHg.
25. Treatment after thrombolysis
• After thrombolysis, patients are admitted to the ICU or SU for monitoring.
• Close observation includes oral mucosa, puncture site, urine color,
traumatic site and vomiting.
• neurologic function assessments are performed every 15 min during and
after IVT therapy, and then once every 30 min for 6 h, once every hour
thereafter until 24 h after treatment .
• CT examination will be conducted at any time for patients with disease
changes.
• If NIHSS score more than four points at baseline is defined as hemorrhagic
transformation after thrombolysis, according to the amount of bleeding,
whether surgery is needed to do is immediately evaluated.
• if there is no indication for surgery, cold precipitation, platelets, plasma,
vitamin K1, tranexamic acid and other drugs can be used for symptomatic
treatment, and the patient’s vital signs and NIHSS score changes should be
closely monitored
• If there is no bleeding, anti-platelet aggregation drugs (aspirin 100 mg/day,
clopidogrel 75 mg/day) are given 24 h after surgery.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35. Sonothrombolysis
• Sonothrombolysis is a portable, inexpensive, and noninvasive tool for identifying
occlusions in patients with stroke.
• The adjuvant continuous ultrasound-based sonication of an intra-arterial occlusive
thrombus during thrombolysis, enhances the clot-dissolving capabilities of
intravenous thrombolysis, presumably by delivering mechanical pressure to the
surrounding fluids.
• Recently, some published trials examining the efficacy of ultrasound with standard
intravenous thrombolysis have shown that sonothrombolysis has beneficial effects
on recanalization and short-term outcomes in patients with acute ischemic stroke.
36.
37.
38.
39.
40. IV TPA- LIMITATIONS
• ICA and M1 occlusions have lower rate of recanalization than M2-M4
occlusions.
• 52% with NIHSS <10 will reach NIHSS of 1 after IV Tpa, but only 8% with
NIHSS>20
• 30% of MCA occlusions recanalize with IV Tpa only within 2 hours
• ICA occlusions recanalize only at 1/3 of the rate of MCA occlusions.
41. Logistic regression curve representing an estimate of the probability for
successful recanalization of occluded vessels by IVT depending on
thrombus length
42. Endovascular management
• Sussman and Fitch described the IA treatment of acute carotid occlusion
with fibrinolysin injection in 1958.
• Late 1990s experienced exponential progress and development.
• Early treatments with intra-arterial thrombolysis and insertion of
permanent stents and clot extraction devices, such as the Mechanical
Embolus Removal in Cerebral Ischaemia (MERCI) device, evolved into the
stent retriever devices used in most of the pivotal trials and, more
recently, aspiration devices.
• Recently, the concept of “tissue window” versus time window has proved
useful for selecting patients for mechanical thrombectomy up to 24 hours
from symptom onset
43. Ischemic penumbra :the area of brain tissue that is still viable but is critically
hypoperfused and will progress to infarct in the absence of timely reperfusion
• The paradigm of “time is brain” has been vital to strengthen the
importance of rapid treatment in acute stroke, several investigations have
demonstrated that other factors contribute to the degree of ischemic
injury at any point in time.
44. Areas of ischaemia following middle cerebral artery occlusion before (left)
and after (right) reperfusion
46. Tissue vs. Time window
<3hrs
Early time is surrogate
marker for pneumbra
=
Imaging required
to assess
pathophysiology
>3hrs
Time from onset(hrs)
p
n
e
u
m
b
r
a
47. COLLATERAL CIRCULATION
• Survival of brain tissue supplied by an occluded or very stenotic artery
depends on
(1) the status of the obstruction (circulation may be restored either
spontaneously or by active treatment to dissolve or mechanically remove the
blockage);
(2) in case of partial occlusions, the ability of the systemic
circulation to adequately supply the ischemic region through augmented flow
either spontaneously or through therapeutic interventions such as induced
hypertension; and
(3) the presence and strength of collateral blood supply.
48. • Cerebral collaterals can be broadly divided into
1. the short bypass segments at the circle of Willis (primary collaterals)
2. the elongated leptomeningeal anastomotic routes able to deliver
retrograde perfusion to adjacent vascular territories (secondary
collaterals)
Each middle oval indicates
the potential connecting
vessels between the left and
right arteries in the
intracranial (A) and
extracranial-intracranial (B)
circulations.
49. NEUROIMAGING FOR SELECTING PATIENTS FOR ACUTE
ENDOVASCULAR THERAPIES
• An initial evaluation with a non contrast CT scan is necessary.
• Penumbra Pivotal Stroke Trial
1. Retrospective analysis of 85 patients
Results:
• Baseline CT scan by ASPECTS score >7 had a 50%chance of a favorable
clinical outcome with early recanalization
• ASPECTS scores <4 did not show clinical improvement regardless of
endovascular recanalization.
50. • Large territorial infarcts
High risk of hemorrhagic conversion
Poor candidates for endovascular therapy.
• Intra parenchymal hematoma is contraindication to endovascular
recanalisation
• Presence of a hyperdense MCA sign on the initial head CT does not have a
significant prognostic value in patient outcome and vessel recanalisation
rates.
51. CT PERFUSION SCANS
• Perfusion scan
demonstrates the
pneumbra lesion volume or
mean transit time which is
essential for determining
outcomes.
52. Angiographic evaluation
• To see for ischemic etiology and initiation of treatment.
• Based on the pt symptoms and pre procedure imaging,
selective catheterization of the carotid or vertebrobasilar
circulation supplying affected territory is performed.
• Grade of collaterals is a decisive factor for the degree of
reperfusion and clinical improvement.
53. REPERFUSION STRATERGIES
•Recanalization or antegrade reperfusion
•Global reperfusion(flow augmentation or transarterial
retrograde reperfusion)
•Transverse retrograde reperfusion (flow reversal)
54. Intraarterial chemical thrombolysis
• Agents converts plasminogen into plasmin degrades
fibrin and products.
• Recombinant tissue plasminogen activator(rtPA) and
recombinant urokinase have been widely studied and used
most frequently.
• Third generation agents such as reteplase and tenecteplase
have longer half lives(15-18 min) and favourable for
recanalization and lower recurrence rates.
• Half life of alteplase is 3.5min and urokinase is 7min.
55. • The aforementioned agents have prothrombotic effects by production of
thrombin during thrombolysis and subsequent activation of platelets and
fibrinogen.
• Concomitant use of systemic anticoagulation is recommended with
caution risk of ICH.
• Commonly used anti coagulant – heparin
Memon and colleagues study
Reviewed 35 cases of adjunctive use of eptifibatide in salvage reocclusion and
thrombolysis of distal thrombi with single bolus of 180µg/kg.
They reported a partial to complete recanalization of 77% with incidence of
post operative hemorrhage was 37%
56. Anterior circulation
• Middle cerebral artery
Three major clinical trials evaluated the efficacy of IA
thrombolysis in MCA circulation
1. PROACT I and II (Prolyse in Acute Cerebral
thromboembolism)
2. MELT trials(Middle Cerebral Artery Local Fibrinolytic
Intervention Trial)
57. PROACT1
• 40 patients were randomized for treatment of acute ischemic stroke
within 6hours of symptom onset
• Cerebral angiography was performed and M1 and M2 occlusions
were treated with 6mg of rpro-UK(n=26) or placebo|(n=14)
• Results: Rpro-UK treated patients had higher vessel recanalization
rates compared to placebo(57.7% vs14.3%). The incidence of ICH
was higher in rpro-UK group(15.4% vs 7.1%)
58. PROACT 2
• This randomized, controlled clinical trial treated pts with MCA
occlusion within 6hrs of symptom onset with either 9mg of IA
rpro-UK and heparin infusion(n=121) or heparin infusion
alone(n=59)
• Results: pts who received IA rpro –UK had significantly lower
Rankin scores at the 90 day endpoint compared to heparin
only treated pts.
59. Theron et al study
• Investigated the efficacy of IA thrombolysis in pts who
had acute ICA with MCA occlusion.
Results:
1. IA fibrinolysis of the MCA should be performed within
6hrs from ischemic onset, when occlusion involves the
horizontal segment of MCA extended into
lenticulostriate arteries.
2. If occlusion does not involve the horizontal MCA
segment and lenticulostriate arteries, then the
treatment window can extended to 12hrs following
symptoms.
60. Internal carotid artery
• Occlusions of extracranial ICA have better prognosis than intracranial ICA.
• Pts with insufficient collaterals or incomplete circle of willis may be
predisposed to significant neurological symptoms.
• Mechanical thrombolysis +pharmacological thrombolysis is of paramount
importance for recanalization.
• Flint et al published a series of 80 patients with ICA occlusion who were
treated with combinations of MERCI retriever with or without adjunctive
endovascular therapy. Recanalization rates were higher in the combination
group(63%) as opposed to MERCI group(53%)
• Arnold and colleagues presented a series of 24pts with distal ICA
occlusions treated with IA urokinase. Favourable 3 month functional
outcome was present in only 16%of pts and mortality rate was
approximately 42%
61. Posterior circulation
• Basilar artery occlusion is a life threatening event with untreated BA
occlusion having ,mortality rates ranging from 86% to 100%.
• In a series of nearly 300 patients, Furlan and Higashida reported an IA
recanalization rate of 60% and mortality rate 31%
• Lindsberg and matte compared BA occlusion treatment with IV or IA
thrombolysis.
• Results: recanalization rates were higher with IA treatment (65%vs 53%)
but death rates were equal between two groups.
• BASICS STUDY (Basilar Artery International Cooporation Study) 624 pts
with radiographically confirmed occlusion of the BA were enrolled in
nearly 50 centers over a 5yr period.
• Results: all pts treated with IA or IV thrombolytics beyond 9hrs from
symptom onset had a poor reported outcome.(therapeutic window 6-
9hrs)
62. Intraarterial mechanical thrombolysis
Broadly categorized into the following categories:
• Thrombectomy
• Thromboaspiration
• Thrombus disruption
• Augmented fibrinolysis
• Thrombus entrapment
63. Mechanical thrombectomy
• First generation:
Merci Retriever(mechanical embolus removal in cerebral ischemia)
Penumbra system devices
• Second generation:
Solitaire flow restoration device
Trevo retriever
64.
65. Mechanical thrombectomy
a)Wire and catheter passed from femoral artery, over aortic arch, through ICA ,
to MCA and through the clot
b)Guide catheter removed and stent catheter advanced over the wire through
the clot
a b
66. c)Catheter pulled back, stent deployed into clot
d)Stent embedded in clot- traps the clot within device
mesh
c
d
Stent with embedded clot pulled back into guide catheter.
67. Endovascular thromboaspiration
• Aspiration technique which is suited for fresh non adhesive clots. These
devices also have advantage of fewer embolic material and decreased
vasospam.
• Penumbra stroke system is increasingly popular and uses 2 types of
devices to remove occlusive thromboembolus in acute ischemic stroke.
• Penumbra devices act on the proximal face of occlusion without traversing
the occluded artery.
• An aspiration device is used to debulk and extract the clot.
• A second retriever device resembling a stent attached to a guide wire is
used to remove resistant clot.
68. Mechanical thrombus disruption
• Mechanical disruption of clot is accomplished via a
microguidewire or a snare.
• Risks of vessel rupture and distal embolisation
• Some devices utilizing this mechanism are
EPAR(Endovascular,Belmont,California) and the LaTIS laser
device(LaTIS, Minneapolis,Minnesota)
69. Thrombus entrapment
• Utilizes a stent to recanalize the occluded vessel and therefore trap the
clot between the stent and vessel wall.
• Stents can be deployed via a balloon mechanism or could be self
expandable.
• Becoming popular due to their flexibility and ease of navigation
70. Solitaire and trevo
Stentriever
• Self expandable
• Retrievable
• Dual functionality:
Acts as a temporary intracranial bypass providing immediate flow
restoration through the thrombus
Acts as clot retriever, trapping thrombus into its cells allowing for clot
removal
72. Evidence for mechanical
thrombectomy in 2013
• 3 randomized trials comparing IV-tPA to IA therapy published
in NEJM in 2013 found no difference in clinical outcomes:
IMS II
SYNTHESIS EXPANSION
MR RESCUE
73. IMS III trial
• International RCT comparing
standard dose IV-rtPA and
mechanical thrombectomy.
• No pre procedure vascular
imaging was required before
enrolling pts for the study,
which led to 89 pts enrolled in
endovascular arm without
LVO.
• MERCI device was only FDA
appproved for the study.
• In 2012, study was stopped
due to futility and showing no
significant difference
74. SYNTHESIS trial
• Randomized pts into IV-
rtPA or endovascular
arms.
• Vascular imaging was not
mandatory to randomise
pts in endovascular arm.
• 2nd generation devices
were used in 13%pts
undergoing endovascular
treatment
• No functional benefit of
endovascular therapy was
observed (p=0.37)
75. MR RESCUE trial
• RCT of 1st generation
device MT in anterior
circulation in pts
randomized by MRI
perfusion imaging, in
addition to randomization
of embolectomy vs
medical therapy.
• There were no significant
differences between ,MT
and medical therapy
groups, regardless of
recanalization status.
78. Recent advances in treatment
• Higher rates of successful recanalization
• Marked reduction in thrombectomy procedures times.
• Translates into improved outcomes
79. A Multicenter Randomized CLinical trial of Endovascular
treatment for Acute ischemic stroke in the Netherlands (MR
CLEAN)
• Sites: 16 centers in Netherlands
• Patients: 500
– 233 randomized to IA
thrombectomy
– 267 randomized to medical
management
• Age 18+
• Included mild-severe stroke
severity
• Time: Treatment initiated within
6 hrs
• Primary Outcome: mRS at 90 days
• Treatment in IA arm: No
requirement, but retrievable
stent in majority
80. A Multicenter Randomized CLinical trial of Endovascular
treatment for Acute ischemic stroke in the Netherlands (MR
CLEAN)
• Good Outcome (mRS 0-2):
– 33% in IA thrombectomy
group
– 19% in medical group
• Conclusion:
Significantly better
outcomes with
thrombectomy compared to
medical management
81. Endovascular Treatment for Small Core and Proximal Occlusion
Ischemic StrokE (ESCAPE)
• Sites: 22 centers mostly in N
America
• Patients: 315 (halted early due to
efficacy)
– 165 randomized to IA
thrombectomy
– 150 randomized to medical
• Age 18+
• Included mild-severe strokes
• Time: Treatment within 12 hours
of onset
• Primary Outcome: mRS at 90 days
• Treatment in IA arm: Retrievable
stent
82. Endovascular Treatment for Small Core and Proximal Occlusion
Ischemic StrokE (ESCAPE)
• Good Outcome (mRS 0-
2):
– 53% in IA thrombectomy
group
– 29% in medical group
• Conclusion:
Significantly better
outcomes with
thrombectomy
compared to medical
management
83. Solitaire With the Intention For Thrombectomy as PRIMary
Endovascular treatment (SWIFT PRIME)
• Sites: 39 centers mostly in US and
Europe
• Patients: 196 (halted early due to
efficacy)
– 98 randomized to IA
thrombectomy
– 98 randomized to medical
• Age 18-80
• Included moderate-severe strokes
• Time: Within 6 hours of onset and
within 1.5 hours of imaging
• Primary Outcome: mRS at 90 days
• Treatment in IA arm: retrievable
stent
84. Solitaire With the Intention For Thrombectomy as PRIMary
Endovascular treatment (SWIFT PRIME)
• Good Outcome (mRS 0-2):
– 60% in IA thrombectomy
group
– 35% in medical group
• Conclusion:
Significantly better
outcomes with
thrombectomy compared to
medical management
85. Endovascular Revascularization With Solitaire
Device Versus Best Medical Therapy in Anterior Circulation Stroke
Within 8 Hours (REVASCAT)
• Sites: 4 centers in Spain
• Patients: 206
– 103 randomized to IA
thrombectomy
– 103 randomized to medical
• Age 18-85
• Included mild-severe strokes
• Time: Within 8 hours of onset
• Primary Outcome: mRS at 90
days
• Treatment in IA arm:
retrievable stent
86. Endovascular Revascularization With Solitaire
Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8
Hours (REVASCAT)
• Good Outcome (mRS 0-2):
– 44% in IA thrombectomy
group
– 28% in medical group
87. The five most important published trials on
endovascular therapy in stroke
88.
89. Candidates for Acute Endovascular Stroke Therapy
Inclusion criteria
• Age ≥18 years
• National Institutes of Health Stroke Scale score ≥6
• Time from symptom onset to groin puncture <6 hours (up to 24 hours if
evidence of sizable ischemic penumbra is seen on perfusion imaging)
• Good prestroke functional status
• Alberta Stroke Program Early CT Score ≥6 on baseline CT scan
• Presence of proximal intracranial artery occlusion
Exclusion criteria:
• BP>185/110mmHg
• Blood glucose <2.7 or >22.2mmol/L
• IV treatment with thrombolytic therapy in a dose >0.9mg/Kg
• Coagulation abnormalities(platelet count<40,000/ml or INR >3.0).
90. • The use of mechanical thrombectomy in patients with MCA M2 occlusions
within 6 hours from symptom onset may be reasonable for carefully
selected patients, as is its use in patients who have a prestroke modified
Rankin Scale score greater than 1, ASPECTS less than 6, or NIHSS score less
than 6.
• The benefit of mechanical thrombectomy in patients presenting within 6
hours from symptom onset and occlusion of the anterior cerebral arteries,
vertebral arteries, basilar artery, or posterior cerebral arteries remains
uncertain.
• It is important to highlight that, in all trials previously described, patients
received IV thrombolysis as a bridge to mechanical thrombectomy when
eligible and that the chances of better outcomes at 90 days within the
mechanical thrombectomy group declined with a longer time from
symptom onset to arterial puncture.
• Therefore, observation after IV thrombolysis to evaluate clinical
improvement before mechanical thrombectomy should not be performed.
92. Conclusions
• Recent endovasculasar acute stroke trials have demonstrated
the superiority of combined treatment with MT and IV-rtPA
over medical therapy alone for pts with LVO who present
within 6hr.
• This is a revolutionary advance in ability to combat the
massive disability that results from stroke.
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