It had been a few weeks since I perused the recently published articles in Stroke – and there were so many: 1) not quite enough for their own angry post, but 2) worth noting, so, here we are:
Emergency Department Door-to-Puncture Time Since 2014: Observations From the BEST-MSU Study
https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.025106
This one comes with the nonsensical medical lay press article entitled “Mobile stroke units get patients to hospital faster than ambulances“. No, mobile stroke units do not warp the fabric of space-time. They are bound by the same laws of physics and traffic as the rest of us.
What this study actually shows is the difference between door-to-groin-puncture time in patients arriving via the MSU versus regular EMS. The result: it saved about 10 to 15 minutes to have the pre-hospital neurologist evaluation in-person or via telemedicine. Considering the observational evidence regarding the fragility of collateral circulation within the first few hours of large-vessel stroke, this is obviously favorable – but the actual clinical effect of a few minutes can only be minimal at best.
Functional Outcome Following Stroke Thrombectomy in Clinical Practice
https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.026005
A huge German registry of stroke thrombectomy provides some insights into the “real world” outcomes. These authors spend a little time comparing their outcomes to those observed in the meta-analysis of the trials, but this comparison is obviously challenging due to the entry and perfusion imaging selection criteria of the trials. The big takeaway, however: real world mortality was 28.6% compared with the trial mortality of 15.3%. These findings should prompt further investigation into strategies to reduce risk for death.
Blood Pressure and Outcome After Mechanical Thrombectomy With Successful Revascularization
https://www.ncbi.nlm.nih.gov/pubmed/31318633
This is just an observational series – with a lot of missing data – looking for any association between blood pressure and outcomes following mechanical thrombectomy. The general trend: higher is worse. Something like the normotensive range is associated with the best outcomes and fewest complications. However, such observations cannot be assumed to suggest improving blood pressure control will reduce the frequency of downstream complications. More likely, the blood pressure is rising as a result of the complications – intracranial hemorrhage and cerebral edema – and it is only hypothesis-generating at this stage to say strict control will improve outcomes.
Magnitude of Benefit of Combined Endovascular Thrombectomy and Intravenous Fibrinolysis in Large Vessel Occlusion Ischemic Stroke
https://www.ncbi.nlm.nih.gov/pubmed/31311465
Very few analyses truly spur a full rolling-of-the-eyes, but this is one of them: taking matched cohorts from NINDS and SWIFT-PRIME to conjure up some sort of quantification of the benefit of endovascular therapy in large-vessel occlusion. It isn’t so much the basic principle of the analysis with which I quibble – but the fact they are only able to roll with 80 patients each from their NINDS tPA, NINDS placebo, and SWIFT-PRIME cohorts. Of course, if you recall, large-vessel occlusions were not specifically identified in NINDS, so these authors are imputing their presence based on NIHSS and deficit patterns, which is hardly a reliable means of identification. Then, with only 80 patients in each cohort, the imprecision of each comparison is so great it’s virtually pointless to rely on these findings in the patient-facing shared-decision-making information graphics they created. Without reading too much between the lines regarding why this nonsense was ultimately published, it should be noted the lead author is Jeff Saver’s son.