Overview. International Stroke Conference Update Clot buster use rises most among 80 and older stroke patients ACUTE STROKE 2/13/2015

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1 Overview International Stroke Conference Update 2015 Nerissa U. Ko, MD, MAS University of California, San Francisco Recent Advances in Neurology February 13, 2015 Nothing to disclose Non-endovascular treatment of Acute Ischemic Stroke Stroke prevention Stroke rehabilitation Clot buster use rises most among 80 and older stroke patients ACUTE STROKE Michelle P. Lin, M.D., M.P.H., University of Southern California, Los Angeles, Calif. Researchers analyzed the health records of nearly 6 million patients admitted to U.S. hospitals between 2000 and 2010for strokes treated with IV tpa Study participants were 35 percent 80 years and older, 37 percent 65 to 79 years of age, and 28 percent were 18 to 64. 1

2 Clot buster use rises most among 80 and older stroke patients They found that tpaadministration rate increases from 2000 to 2010 were: 0.47 to 3.55 percent for the oldest group studied; 0.92 to 3.87 percent for 65 to 79 year olds; and 1.02 to 3.61 percent in patients ages 18 to 64. Among age >80, those treated at an urban hospital and teaching hospital were more likely to receive tpa. Women, Blacks, Hispanics and Medicaid holders were less likely to receive tpa. Many mild stroke patients considered too good to treat may actually benefit from tpa Stroke patients with mild symptoms might be eligible but often don t receive tpabecause they are deemed too good to treat, but many of these patients don t fare well after stroke Using the Get With The Guidelines database from Boston s Massachusetts General Hospital, researchers analyzed 2,745 consecutive stroke admissions (01/ /2013) to identify which too-good-to treat -patients should be considered for tpabecause of their risk of poor health or death. Many mild stroke patients considered too good to treat may actually benefit from tpa 238 stroke patients arrived in time to receive tpabut did not receive it because their symptoms were too mild or they were rapidly improving 89 did not do well and might have benefitted from tpa. Only 62 percent were discharged home 27 percent went to inpatient rehabilitation facilities 8.4 percent to skilled nursing facilities more than 2 percent either died or went to hospice. Risk factors for having poor outcome: elderly; more severe strokes; Hispanic;strokethat affects both hemispheres Patients with wake-up strokes may be candidates for tpa treatment Andrew D. Barreto, M.D., The University of Texas Health Science Center at Houston, TX. N=40 moderate severity wake-up stroke patients with a broad range of stroke severities and disabling deficits. Patients received tpaan average of 2.6 hours after waking up with stroke symptoms. None of the patients treated had intracerebral hemorrhage, resulting in neurological worsening. 50% made full recoveries at 90 days. 2

3 STROKE PREVENTION Atrial fibrillation and Cryptogenic stroke To help determine if an implantable cardiac monitor (ICM) is effective, researchers analyzed 1,247 cryptogenic stroke patients who received an ICM device post stroke Atrial fibrillation detection rate in the study population was 12.2 percent at 182 days; this was 37 percent higher than what was found in a recent randomized controlled trial (CRYSTAL AF) at the same time. Atrial fibrillation and Cryptogenic stroke Half of the patients with detected atrial fibrillation had an episode that was at least 3.4 hours in duration. Among the patients with atrial fibrillation, 25 percent had an episode that was longer than 11.8 hours. ICMs may have even greater clinical utility in detecting AF in real-world practice than in clinical trials. 3

4 Atrial fibrillation and Cryptogenic stroke Scientists analyzed data from previous studies to determine if detecting atrial fibrillation with an ICM in cryptogenic stroke patients is costeffective compared to standard of care. ICM was associated with fewer recurrent strokes and increased quality of life While stroke-related costs were lower in the ICM group, overall costs were higher than in the standard of care group 4

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