Journal Jam 10 Thrombolysis & Endovascular Therapy for Stroke Part 1

In this 2 part EM Cases Journal Jam podcast Justin Morgenstern, Rory Spiegel and Anton Helman do a deep dive into the world's literature on systemic thrombolysis for ischemic stroke followed by an analysis of endovascular therapy for stroke. We elucidate the important issues related to p-values, ordinal analysis, fragility index, heterogeneity of studies, stopping trials early and conflicts of interest related to this body of evidence. While "calling a code stroke" is now considered standard for most stroke patients and tPA for stroke is considered a class 1A drug, a close look at the literature tells us that the evidence is not as strong as our stroke protocols suggest...



Podcast produced by Anton Helman, Justin Morgenstern and Rory Spiegel; sound design and editing by Anton Helman; EBM bomb by Anton Nikoline.

Written Summary and blog post by Anton Helman July, 2016

Cite this podcast as: Morgenstern, J, Spiegel, R, Helman, A. Thrombolysis & Endovascular Therapy for Stroke Part 1. Emergency Medicine Cases. July, 2016. https://emergencymedicinecases.com/thrombolysis-endovascular-therapy-for-stroke/. Accessed [date].

The systemic thrombolysis for stroke RCTs

Two out of 12 systemic thrombolysis studies suggest a benefit: NINDS-2 and ECASS-3.

NINDS-1 tested neurologic improvement at 24 hours and found no benefit.

NINDS-2 subjects in the thrombolytic arm experienced milder strokes than those in the placebo arm.

Outcome measure = “chance of a good outcome”  12% better (even though goal was to show 20%)

Overall: Benefit = NNT of 8 for post-hoc "favorable outcome" measure

MAST-I 1995 -