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Stroke Trials

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Aspirin in stroke(IST, CAST, CAPRIE) Heparin in stroke ( CAST, HAEST) Thrombolytics in stroke Warfarin in stroke Stroke unit care Primary prevention AF and stroke prevention Carotid endarterectomy Carotid stenting Intracranial stenting 8/17/12

Aspirin
IST Randomised open trial involving 20000

patients

statistically significant difference in the number

of deaths and recurrent strokes between patients receiving aspirin vs. no aspirin

CAST Aspirin vs placebo Randomized-

controlled trial of 21106 patients at 413 Chinese hospitals.


significant (14%, SD 7) proportional reduction in

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and fewer recurrent ischemic strokes

Thrombolysis
NINDS-TPA To test the potential benefit of t-PA

when administered within 3 hours of stroke onset.

Randomized, double-blind trial Part 1: tested whether t-PA had clinical

activity (291)

Part 2: assess clinical outcome at three

months, according to scores on the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS(333)

Study Size: 624

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NINDS TPA Results


In part 1, there was no significant difference between the

group given t-PA and that given placebo in the percentages of patients with neurologic improvement at 24 hours, although a benefit was observed for the t-PA group at three months for all four outcome measures.
As compared with patients given placebo, patients treated

with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales. the onset of stroke occurred in 6.4 percent of patients given t-PA but only 0.6 percent of patients given placebo (P < 0.001).

Symptomatic intracerebral hemorrhage within 36 hours after

Mortality at three months was 17 percent in the t-PA group 8/17/12

Other Thrombolysis trials


Streptokinase
ASK n=340 <4hrs MAST I n=622 MAST - E n=360
Increased early death; all 3 trials stopped early

TPA
ECASS 1 increased risk of hemorrhage NINDS outweighed risk 30% reduction in death and disability; 6-7 % risk of ICH but benefit

ECASS 2
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ATLANTIS A & B

Metaanalysis
SAVER et al Arch Neurology 2004 61:1066-

1070

LEES Lancet 2004 363: 768-774

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Thrombolysis beyond 3 hours


EPITHET DIAS DEDAS DEFUSE

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Intra-arterial
PROACT 1 PROACT 2

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DIAS 3
The purpose of the study is to determine

whether desmoteplase is effective and safe in the treatment of patients with acute ischaemic stroke when given within 3-9 hours from onset of stroke symptoms.

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CREST
stent-assisted carotid angioplasty (CAS) to the traditional

and accepted surgical approach of carotid endarterectomy (CEA) for the treatment of carotid artery stenosis to prevent recurrent strokes in those patients who have had a TIA (transient ischemic attack) or a mild stroke
Carotid stenting was associated with a 7.2% rate of stroke,

myocardial infarction, or deaththe composite primary endpointcompared to 6.8% for carotid endarterectomy. EFFECTIVE AS CONVENTIONAL SURGERY

CAROTID ARTERY STENTING IS AS SAFE AND

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CAVATAS
504 patients with stenosis of the carotid

artery (90% symptomatic) were randomly assigned to endovascular treatment (n=251) or surgery (n=253).

In conclusion, more patients had stroke

during follow-up in the endovascular group than in the surgical group 8/17/12

EVA 3S
Trial stopped early as stenting was felt to be

too dangerous (most patients has distal protection)

The 30-day incidence of any stroke or death

was 3.9% after endarterectomy and 9.6% after stent placement.

At 6 months, the incidence of any stroke or

death was 6.1% after endarterectomy and 11.7% after stent placement.

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SAPPHIRE2002
Stenting and Angioplasty with Protection in

Patients at High Risk for Endarterectomy (SAPPHIRE)

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SAMMPRIS
To determine whether intracranial stenting

(Wingspan stent) with intensive medical therapy is superior to the medical therapy alone for preventing second stroke in high-risk patients with symptomatic stenosis of a major intracranial artery. safety and effectiveness of either Intensive Medical Therapy PLUS Stenting or Intensive Medical Therapy ONLY in preventing stroke, heart attacks or death.

The purpose of this study is to compare the

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CEA vs STENTING
carotid artery stenting vs surgery 13 Trials 7287 Patients Leicester (Naylor) (1998), WALLSTENT

(Alberts) (2001), CAVATAS-CEA (2001), Kentucky A (Brooks) (2001), Kentucky B (Brooks) (2004), SAPPHIRE (yadav) (2004), EVA-3S (Mas) (2000), SPACE (2000), TESCAS-C (Ling) (2006), BACASS (Hoffman) (2006), Steinbauer (2008), 8/17/12 (2010), CREST (2010) ICSS

BP lowering in ICH
ATACH Feasibility study GCS >8, Volume less

than 60

aggressive SBP reduction to 110140 mm Hg in

the first 24 hours using intravenous nicardipine was well tolerated with a low risk of hematoma expansion, neurological deterioration and inhospital mortality.
The results favor pharmacological reduction of

SBP in patients with acute ICH.

INTERACT:
INTERACT 8/17/12

enrolled ICH patients diagnosed by

INTERACT
randomized to intensive blood pressure

reduction (target systolic blood pressure 140 mmHg; n = 203)

VS

standard guideline-based management of

blood pressure (target systolic blood pressure 180 mmHg; n = 201).

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AF
AFFIRM RACE
(Atrial Fibrillation Follow-up of Rhythm Control Management; rate vs rhythm both receiving warfarin, warfarin superior to placebo and aspirin) (Rate vs rhythm control in AF

RACE 2 BAFTA RELY (Dabigatran noninferior to Warfarin

NVAF)

AFASAK(Aspirin vs warfarin, Chr AF, Warf

superior)
SPORTIF 2 and 3 (Ximelagatran in AF compared with Warfarin)
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