Dragon score for predicting success of thrombolysis pub in neurology

Objective: To develop a functional outcome prediction score, based on immediate pretreatment parameters, in ischemic stroke patients receiving IV alteplase.

Methods: The derivation cohort consists of 1,319 ischemic stroke patients treated with IV alteplase at the Helsinki University Central Hospital, Helsinki, Finland. We evaluated the predictive value of parameters associated with the 3-month outcome and developed the score according to the magnitude of logistic regression coefficients. We assessed accuracy of the model with bootstrapping. External validation was performed in a cohort of 330 patients treated at the University Hospital Basel, Basel, Switzerland. We assessed the score performance with area under the receiver operating characteristic curve (AUC-ROC).

Results: The DRAGON score (0–10 points) consists of (hyper)Dense cerebral artery sign/early infarct signs on admission CT scan (both = 2, either = 1, none = 0), prestroke modified Rankin Scale (mRS) score >1 (yes = 1), Age (≥80 years = 2, 65–79 years = 1, <65 years = 0), Glucose level at baseline (>8 mmol/L [>144 mg/dL] = 1), Onset-to-treatment time (>90 minutes = 1), and baseline National Institutes of Health Stroke Scale score (>15 = 3, 10–15 = 2, 5–9 = 1, 0–4 = 0). AUC-ROC was 0.84 (0.80–0.87) in the derivation cohort and 0.80 (0.74–0.86) in the validation cohort. Proportions of patients with good outcome (mRS score 0–2) were 96%, 88%, 74%, and 0% for 0–1, 2, 3, and 8–10 points, respectively. Proportions of patients with miserable outcome (mRS score 5–6) were 0%, 2%, 5%, 70%, and 100% for 0–1, 2, 3, 8, and 9–10 points, respectively. External validation showed similar results.

Conclusions: The DRAGON score is valid at our site and was reliable externally. It can support clinical decision-making, especially when invasive add-on strategies are considered. The score was not studied in patients with basilar artery occlusion. Further external validation is warranted.

Risk of warfarin association with bleeding with antibiotics

Baillergeon J. et al.  Am J Med 2012; 125:183-9.

 

Antibiotic (class)          odds ratio of bleeding (univariate/multivariate)

 

Azole antifungals             6.49/4.57

macrolides                      2.09/1.86

quinolones                      2.20/1.69

cotrimoxazole                 3.06/2.70

penicillins                       1.89/1.92

cephalosporins                2.85/2.45

 

Use of other meds

 

SSRI                               1.45/1.34

SNRI                               1.34/1.17

corticosteroid                   2.58/2.30

antiplatelet                       1.57/1.43

CYP2CP                          1.11/1.07

 

 

sICH after alteplase, on v. not on warfarin

Seet RCS et al.  Stroke 2011; 42:2333-2335

Authors highlight increased risk of alteplase in warfarin patients treated at a single site, irrespective of htn or stroke etiolgy, or INR . 

NNT and NNH with t-pa by time administered

Lansberg et al. Stroke 2009  meta-analysis of 6 stroke trials of t-pa.

Time to treat      NNT            NNH   (NNT= number needed to treat or number needed to harm)

0-90 minutes       3.6                65
90-180 minutes   4.3                38
180-270 min       5.9                30
270-360 min       19.3              14

Debates on Intracranial artery disease (ICAD) at ISC 2012, and imaging

Lessons from Sampris-- Wingspan stent trial was stopped due to more deaths in stent group.  However, issues that were brought out include that sites had inexperienced interventionalists with an average enrollment of 2 per site, total enrollment fairly small, plus criteria for enrollment was not (necessarily) ideal since we don't know who best candidates are.  One comment was that randomized trials if done too early (as here) retard innovation.

 

An  important finding of Sammpris ties in with the theme of the year, which is that medical management has improved. 2 year mortality of ICD declined from 20 percent in earlier trials to about 12 % in Sammpris.  The putative hero is aggressive 2011 medical management, with all it entails for tighter blood pressure control, tighter LDL-c reduction, attention to so called minor risk factors including metabolic syndrome, HDL, CRP and others.

 

One woman commented on her own "no metal " experience with angioplasty and made a case for a clinical trial with "no metal."  The main risk of failure was not seen in her series of series. (Thanh Nguyen).  Thereupon a discussion ensued about whether or not brain arteries are like coronary arteries where we already have learned so much.  Brain arteries have no external lamina are smaller caliber and more prone to perforation. 

 

Tom Brott opined that future trials of ICAD will need to compare procedures with new "best medical."

 

IMAGING

 

Debate again, is over what is best imaging protocol for stroke.  Data was presented that CT-P does NOT improve 90 day modified Rankin scores over regular noncontrast CT as a stratifier.  CT-P does add to time to catheter.  Time to order is a major delay point.  Whatever is used should be comfortable at facility. 

 

Purpose of extra procedures (advanced MRI or CT) is to exclude futile procedures and cases likely to hemorrhage (do no harm) as well as tell anatomy of occlusion to guide procedure. D-P mismatch, as last year, is not key, core infarct size is much more important (can tell best on MRI diffusion studies or possibly CBV). Exceptions are malignant pattern (see DEFUSE trial)  Evaluation of collateral flow is gaining prominence. One speaker commented that they still intervene on the ten percent that imaging says are futile.