5/17/2016 Acutestrokeintervention:asystematicreview.

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JAMA.2015Apr14313(14):145162.doi:10.1001/jama.2015.3058.

Acutestrokeintervention:asystematicreview.
PrabhakaranS1,RuffI1,BernsteinRA1.

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Abstract
IMPORTANCE: AcuteischemicstrokeisamajorcauseofmortalityandmorbidityintheUnited
States.Wereviewthelatestdataandevidencesupportingcatheterdirectedtreatmentfor
proximalarteryocclusionasanadjuncttointravenousthrombolysisinpatientswithacutestroke.
OBJECTIVE: Toreviewthepathophysiologyofacutebrainischemiaandinfarctionandthe
evidencesupportingvariousstrokereperfusiontreatments.
EVIDENCEREVIEW: SystematicliteraturesearchofMEDLINEdatabasespublishedbetween
January1,1990,andFebruary11,2015,wasperformedtoidentifystudiesaddressingtheroleof
thrombolysisandmechanicalthrombectomyinacutestrokemanagement.Studiesincluded
randomizedclinicaltrials,observationalstudies,guidelinestatements,andreviewarticles.Sixty
eightarticles(N=108,082patients)wereselectedforreview.
FINDINGS: Intravenousthrombolysisisthemainstayofacuteischemicstrokemanagementfor
anypatientwithdisablingdeficitspresentingwithin4.5hoursfromsymptomonset.Randomized
trialshavedemonstratedthatmorepatientsreturntohavinggoodfunction(definedbybeing
independentandhavingslightdisabilityorless)whentreatedwithin4.5hoursaftersymptom
onsetwithintravenousrecombinanttissueplasminogenactivator(IVrtPA)therapy.Mechanical
thrombectomyinselectpatientswithacuteischemicstrokeandproximalarteryocclusionshas
demonstratedsubstantialratesofpartialorcompletearterialrecanalizationandimproved
outcomescomparedwithIVrtPAorbestmedicaltreatmentaloneinmultiplerandomizedclinical
trials.Regardlessofmodeofreperfusion,earlierreperfusionisassociatedwithbetterclinical
outcomes.
CONCLUSIONSANDRELEVANCE: IntravenousrtPAremainsthestandardofcareforpatients
withmoderatetosevereneurologicaldeficitswhopresentwithin4.5hoursofsymptomonset.
Outcomesforsomepatientswithacuteischemicstrokeandmoderatetosevereneurological
deficitsduetoproximalarteryocclusionareimprovedwithendovascularreperfusiontherapy.
Effortstohastenreperfusiontherapy,regardlessofthemode,shouldbeundertakenwithin
organizedstrokesystemsofcare.

http://www.ncbi.nlm.nih.gov/pubmed/25871671 1/2
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InterventionforAcuteStrokeReply. [JAMA.2015]
InterventionforAcuteStroke. [JAMA.2015]

PMID:25871671[PubMedindexedforMEDLINE]

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RyanRadecki 2015May0712:37p.m. edited

Over200,000physiciansbelongtotheAmericanMedicalAssociation.TheJournal,therefore,of
thisAssociationhasasignificantaudienceandalongtradition.ContinuingMedicalEducation
insertsinJAMAmayrepresentthebasiceducationofmanynewdevelopmentsforgeneral
practitioners.
Theseauthorsperformasystematicreviewonacutestrokeintervention.Theyidentifyand
review145abstractsutilizingmultiplecombinationsofMeSHtermsandsynonymsforbrain
ischemia/drugtherapy,strokedrug/therapy,tissueplasminogenactivator,fibrinolyticagents,
endovascularprocedures,thrombectomy,timefactors,emergencyservice,treatmentoutcome,
multicenterstudy,andrandomizedcontrolledtrial.Amassiveundertaking,tobesure
consideringtheseauthorsarealsoincludingintraarterialandmechanicaltherapyintheirreview.
Yet,asindicatedintheirevidencereviewchartinthesupplement,theseauthors'strategy
managedtoidentifyonly17RCTsinthewholeofsystemicandendovasculartherapy....
http://www.emlitofnote.com/2015/04/alaughabletpasystematicreview.html
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http://www.ncbi.nlm.nih.gov/pubmed/25871671 2/2