Stroke 2023

มหาวิทยาลัยแคลิฟอร์เนีย ซานฟรานซิสโก UCSF แกรนด์ราวนด์ออนไลน์เรื่อง Stroke 2023 เมื่อ 9 มีนาคม 2023 คลิปเผยแพร่ทาง YouTube เมื่อ 11 มีนาคม 2023

วิทยากร ศ.นพ. แอนดรูว์ โจเซฟสัน หัวหน้าภาควิชาประสาทวิทยา UCSF 

https://meded.ucsf.edu/people/s-andrew-josephson

เล่าความก้าวหน้าการตรวจวินิจฉัยทางรังสีวิทยา การใช้ซอฟท์แวร์ช่วยวินิจฉัย การรักษาด้วยAnticoagulants และ Antiplatelets การรักษาโดยการเอาก้อนเลือดที่อุดตันออกจากหลอดเลือด (Endovascular Thrombectomy) โดยมีตัวอย่างผู้ป่วย 4 ราย

 

Case 1 (4:30 – 30:27)

https://youtu.be/nLM1_UQ_aQ0&t=270

UCSF Stroke Protocol , Non Contrast Head CT, CT Angiography, CT Perfusion

2023 Acute Stroke Timeline  

Intravenous t-PA

Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials

Emberson - The Lancet Vol 384, Issue 9958 , P 1929-1935 Nov 29, 2014

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60584-5/fulltext

Speed Matters : Time is Brain

Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke

Saver - JAMA. 2013;309(23):2480-2488

https://jamanetwork.com/journals/jama/fullarticle/1697967                                                                        TNK : Thrombolysis Alternative

Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial

Menon - The Lancet Vol 400 Issue 10347, P161-169 Jul 16, 2022

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01054-6/fulltext

Neurovascular stent

https://tinyurl.com/ban4zbc2

Neuro IR Suite (Neuro interventional radiology suite)

https://tinyurl.com/mrymtwu5

(19:23)

https://youtu.be/nLM1_UQ_aQ0&t=1163

AI Interpretation of CT perfusion in stroke

https://tinyurl.com/3s9uebtz

ตัวอย่าง ซอฟท์แวร์วิเคราะห์ CT perfusion

https://www.rapidai.com/rapid-ctp

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct

Nogueira N Engl J Med 2018; 378:11-21

https://www.nejm.org/doi/full/10.1056/NEJMoa1706442

Diffusion Weighted Imaging (DWI) or Computerized Tomography Perfusion (CTP) Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention (DAWN)

https://clinicaltrials.gov/ct2/show/NCT02142283

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging

Albers N Engl J Med 2018; 378:708-718

https://www.nejm.org/doi/full/10.1056/NEJMoa1713973

DEFUSE 3

https://clinicaltrials.gov/ct2/show/NCT02586415

(23:30)

https://youtu.be/nLM1_UQ_aQ0&t=1410

บทความหนังสือพิมพ์ นิวยอร์คไทมส์ 1มีนาคม 2023 : This Revolutionary Stroke Treatment Will Save Millions of Lives. Eventually.

https://dnyuz.com/2023/03/01/this-revolutionary-stroke-treatment-will-save-millions-of-lives-eventually/

Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well The SELECT Late Study

Sarraj - JAMA Neurol. 2023;80(2):172-182

https://jamanetwork.com/journals/jamaneurology/fullarticle/2799619

A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke

LeCouffe - N Engl J Med 2021; 385:1833-1844

https://www.nejm.org/doi/full/10.1056/NEJMoa2107727

Embolectomy for Large Infarct

Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct

Huo - N Engl J Med 2023; 388

https://www.nejm.org/doi/full/10.1056/NEJMoa2213379

Trial of Endovascular Thrombectomy for Large Ischemic Strokes

Sarraj - N Engl J Med 2023; 388

https://www.nejm.org/doi/full/10.1056/NEJMoa2214403

Thrombolysis in stroke

https://tinyurl.com/yr5mt64c

Endovascular thrombectomy in stroke

https://tinyurl.com/32pfxw3x

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Case 2  (30:28 – 41:56)

https://youtu.be/nLM1_UQ_aQ0&t=1828

Diffusion weighted MRI brain

https://tinyurl.com/5n73365j

Large vessel stroke

https://tinyurl.com/bp69nmrd

Transesophageal Echocardiography (TEE) Is Superior to Transthoracic Echocardiography (TTE) in Management of Patients of Any Age With TIA or Stroke

de Bruijn Stroke. 2006;37:2531–2534

https://www.ahajournals.org/doi/10.1161/01.STR.0000241064.46659.69

The value of transesophageal echocardiography (TEE) for embolic strokes of undetermined source

Katsanos Neurology September 06, 2016; 87 (10) 

https://neurology.org/content/87/10/988

Atrial Fibrillation in Patients with Cryptogenic Stroke

Gladstone N Engl J Med 2014; 370:2467-2477

https://www.nejm.org/doi/full/10.1056/NEJMoa1311376

Effect of Long-term Continuous Cardiac Monitoring vs Usual Care on Detection of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel DiseaseThe STROKE-AF Randomized Clinical Trial

Bernstein JAMA. 2021;325(21):2169-2177

https://jamanetwork.com/journals/jama/fullarticle/2780490

WARCEF

Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm

Homma N Engl J Med 2012; 366:1859-1869

https://www.nejm.org/doi/full/10.1056/nejmoa1202299

CADISS

Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial

LancetNeuro 2015 Apr Vol14 Issue 4: 361-367

https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(15)70018-9/fulltext

Antiphospholipid Syndrome (APLS) hypercoagulable state

https://tinyurl.com/4c3aaaum

Patent foramen ovale (PFO) and stroke

https://tinyurl.com/2p88cvu6

Anticoagulant in stroke

https://tinyurl.com/35b7yh3f

Antiplatelet in stroke

https://tinyurl.com/bdhedp58

Targeted use of heparin, heparinoids, or low-molecular-weight heparin to improve outcome after acute ischaemic stroke: an individual patient data meta-analysis of randomized controlled trials

Whiteley LancetNeuro. 2013 Jun ,vol 12, issue 6: 539-545

https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(13)70079-6/fulltext

-----------------------------

Case 3  (41:57 – 48:39)

https://youtu.be/nLM1_UQ_aQ0&t=2517

Antiplatelet in stroke

https://tinyurl.com/bdhedp58

CHARISMA trial (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization Management and Avoidance)  

https://tinyurl.com/4tbxxu2u

SPS3 trial (Secondary Prevention of Small Subcortical Strokes)

https://tinyurl.com/bde4wd3r

Platelet-Oriented Inhibition in New TIA (POINT) Trial

https://tinyurl.com/5n8csub5

NIH Stroke Scale/Score (NIHSS)

https://tinyurl.com/mr433c77

ABCD Score [age (A), blood pressure (B), clinical features (C), and duration (D)]

https://tinyurl.com/2s3f5eny

Transient IscHaemic Attack Treated with TicAgrelor and ASA for prevention of Stroke and death (THALES)

https://tinyurl.com/msf8y9ek

Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA

Johnston N Engl J Med 2018; 379:215-225

https://www.nejm.org/doi/full/10.1056/NEJMoa1800410

Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA

Johnston N Engl J Med 2020; 383:207-217

https://www.nejm.org/doi/full/10.1056/NEJMoa1916870

Permissive hypertension

https://tinyurl.com/4r8ffd9m

---------------------------------

Case 4  (48:40 – 52:15)

https://youtu.be/nLM1_UQ_aQ0&t=2920

Validation and refinement of scores to predict very early stroke risk after TIA

Johnston The Lancet 2007 Jan Vol 369 , Issue 9558: 283-292

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60150-0/fulltext

A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects

Lavallée LancetNeuro. 2007 Nov Vol 6 , Issue 11 :953-960

https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(07)70248-X/fulltext

Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison

Rothwell The Lancet 2007 Oct ,Vol 370, Issue 9556: 1432-1442

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61448-2/fulltext

One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke

Amarenco N Engl J Med 2016; 374:1533-1542

https://www.nejm.org/doi/full/10.1056/NEJMoa1412981

North American Symptomatic Carotid Endarterectomy Trial (NASCET)

https://tinyurl.com/yd4rvhpt

Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST)

https://tinyurl.com/582a33ss

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Brott N Engl J Med 2010; 363:11-23

https://www.nejm.org/doi/full/10.1056/NEJMoa0912321

ถาม - ตอบ (52:17-60:30)

https://youtu.be/nLM1_UQ_aQ0&t=3137

TIA ให้ Thrombolysis ไหม

CT Scan, CT Perfusion CTA สามารถทำได้หลายแห่งในสหรัฐ การวินิจฉัยก็ง่ายขึ้น ควรสนับสนุนด้าน Teleneurology เพื่อปรึกษากับผู้เชี่ยวชาญ จะช่วยให้ระบบส่งต่อผู้ป่วยดีขึ้น

ควรมีความร่วมมือกัยอย่างใกล้ชิดระหว่าง Neurologist และแพทย์เวชศาสตร์ฉุกเฉิน เพื่อให้ผู้ป่่วย Stroke ฉุกเฉินได้รับการรักษาที่เหมาะสม

ผู้ป่วย Stroke อายุน้อย ปํญหาต้นเหตุมักเกิดจากโรคหัวใจ ควรได้รับการตรวจถี่ถ้วนเรื่องหัวใจ