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Thrombectomy’s success treating strokes prompts rethinking of selection criteria


 

EXPERT ANALYSIS FROM ISC 2018


Current practice often uses imaging “to exclude the 20% of patients who may not have a large vessel occlusion or may not get benefit but whom we are unlikely to harm. But we harm the other 80% by delaying treatment by 30 minutes because of imaging. That’s why we need to rethink imaging and minimize its use.”

Dr. Jovin noted that at his center in Pittsburgh, the stroke institute staff began in 2013 to take patients transported from other stroke facilities and already diagnosed with a large vessel occlusion directly to the angiography suite, bypassing further brain imaging. By doing this, they cut their average door-to-groin puncture time down to 22 minutes from what had been an average of 81 minutes with imaging (Stroke. 2017 July;48[7]:1884-9). Right now the door-to-groin time is even lower, he added.

Dr. Raul G. Nogueira Mitchel L. Zoler/Frontline Medical News

Dr. Raul G. Nogueira

“Should we stratify patients by their core volume? You can have a patient with a core volume of 80 cc but a hypoperfusion volume of 170 cc. This infarct could more than double in size,” Raul G. Nogueira, MD, said in his presentation at the conference. He said patients with large core infarcts have received substantial benefit from endovascular therapy when the stroke location’s region of eloquence was low and the patient’s biological age was also low.

“Don’t waste time imaging,” said Dr. Nogueira, a stroke neurologist who is director of the neuroendovascular division of the Marcus Stroke and Neuroscience Center and professor of neurology, neurosurgery, and radiology at Emory University, both in Atlanta, as well as the second lead investigator for DAWN. “Time is crucial and trumps patient selection. Most selection criteria are informative rather than truly selective. It is important to understand that in every time window, we do not yet know who doesn’t benefit from treatment. Select faster, select less, and treat more” during the 0- to 6-hour window, he told his colleagues.

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