Expansion of Intravenous Tissue Plasminogen Activator Eligibility Beyond National Institute of Neurological Disorders and Stroke and European Cooperative Acute Stroke Study III Criteria.

Intravenous tPA is the standard treatment for acute ischemic stroke. Multiple contraindications for thrombolysis developed during the design of the clinical trials may be overly cautious and limit the number of patients who may be eligible and potentially benefit from treatment. As clinicians have become more comfortable with off-label use of tPA, new data on the safety of thrombolysis have become available and shaped the current guidelines. This article updates our knowledge on the evidence available for these contraindications to help guide the clinician in choosing the optimal approach to some of the most commonly encountered clinical scenarios.

Too good to treat? Outcomes in patients not receiving thrombolysis due to mild deficits or rapidly improving symptoms.

INTRODUCTION: Among ischemic stroke patients arriving within the treatment window, rapidly improving symptoms or having a mild deficit (i.e. too good to treat) is a common reason for exclusion. Several studies have reported poor outcomes in this group. We addressed the question of early neurological deterioration in too good to treat patients in a larger prospective cohort study. METHODS: Admission and discharge information were collected prospectively in acute stroke patients who presented to the emergency room within three-hours from onset. The primary outcome measure was change in the National Institutes of Health Stroke Scale from baseline to discharge. Secondary outcomes were discharge National Institutes of Health Stroke Scale >4, not being discharged home, and discharge modified Rankin scale. RESULTS: Of 355 patients who presented within three-hours, 127 (35·8%) had too good to treat listed as the only reason for not receiving thrombolysis, with median admission National Institutes of Health Stroke Scale = 1 (range = 0 to 19). At discharge, seven (5·5%) showed a worsening of National Institutes of Health Stroke Scale ≥1, and nine (7·1%) had a National Institutes of Health Stroke Scale >4. When excluding prior stroke (remaining n = 97), discharge status was even more benign: only five (5·2%) had a discharge National Institutes of Health Stroke Scale >4, and two (2·1%) patients were not discharged home. CONCLUSION: We found that a small proportion of patients deemed too good to treat will have early neurological deterioration, in contrast to other studies. Decisions about whether to treat mild stroke patients depend on the outcome measure chosen, particularly when considering discharge disposition among patients who have had prior stroke. The decision to thrombolyze may ultimately rest on the nature of the presentation and deficit.

Association of low ejection fraction with impaired verbal memory in older patients with heart failure.

BACKGROUND: Cognitive dysfunction has a major role in health outcomes for cardiac patients. The association of cognitive dysfunction with heart failure is well established, but the cardiac variables that contribute to cognition are not well understood. OBJECTIVES: To investigate the relationships among age, memory, and left ventricular ejection fraction (EF) in patients with heart failure. DESIGN: Retrospective study. SETTING: Academic medical center. PARTICIPANTS: A total of 207 patients with heart failure underwent neuropsychological assessment of memory on standardized tests. MAIN OUTCOME MEASURES: Patients were grouped by age quartiles, and memory function was compared in those with an EF below 30% vs those with an EF of 30% or higher. RESULTS: Demographic, cognitive, and medical variables having a significant association with a memory composite score were identified in a univariate linear regression analysis. In a multivariate linear model that adjusted for significant covariates, there was a significant interaction between age and EF for memory function. Patients younger than 63 years maintained stable memory function across EF levels, but patients 63 years or older showed a significant decline in memory performance when EF dropped below 30% (P < .02). Post hoc multivariate analysis showed that verbal delayed recall and recognition were the components of memory most affected by low EF. CONCLUSION: The effect of EF on memory differs by age such that older patients with lower EFs have significantly reduced verbal memory function.

Treatment of carotid artery disease: endarterectomy or angioplasty?

The management of carotid stenosis has enjoyed renewed interest in the neurological community in recent years due to the advent of endovascular approaches. In concert, progress in medical treatment of these patients has rekindled the debate regarding the best management of carotid stenosis overall, both for symptomatic and asymptomatic disease. For symptomatic carotid stenosis, the major decision required is choosing the type of intervention best suited for individual patients: carotid endarterectomy versus carotid artery stenting. For patients with asymptomatic carotid stenosis, intensive medical management has evolved significantly over the past decade to decrease the risk of ischemic stroke to match surgical intervention under most circumstances. This review will examine the supporting evidence for each intervention, and discuss the recent advances in medical and endovascular therapy that provide the data for a new era in clinical decision making.