In-hospital Management of Stroke
April 1, 2017
By Matthew E. Fink, MD, Editor
Feil Professor and Chairman, Department of Neurology, and Assistant Dean of Clinical Affairs, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a consultant for Procter & Gamble.
Head Position After Ischemic Stroke
Craig Anderson, from Sydney, Australia, presented the results from the HeadPoST trial, which compared supine, head-flat position to head-up position > 30°, in 11,000 patients consecutively admitted to 114 hospitals in nine countries. The patients were randomized using a cluster-designed, randomized, crossover trial, with each hospital serving as a separate randomizing site. The study was designed to answer the question of whether head position, which may alter collateral cerebral blood flow, would have an effect on outcome after ischemic stroke, both in terms of improved functional outcome and frequency of adverse events, such as aspiration pneumonia or cardiac-respiratory impairment. The primary outcome measurement was modified Rankin score at 90 days. Results showed that there was no difference in disability outcomes in either group, even after subgroup analysis for stroke type, age, or differences in comorbidities. In addition, there were no differences in either group regarding the frequency of adverse events, and pneumonias occurred in 3% of both the head-flat group and the head-up group. Therefore, the conclusions of the HeadPoST study are that head position does not have an effect on either functional recovery or adverse events, and may be used according to local nursing practices. However, this study points to a need to evaluate various nursing practices and determine best nursing care practices.
Cilostazol in Ischemic Stroke
Sun Kwon, from Seoul, Korea, presented the results of safety and efficacy of cilostazol treatment in patients with ischemic stroke who were at risk for cerebral hemorrhage. This study was performed in East Asia as a multicenter, controlled trial of ischemic stroke patients at high risk for cerebral hemorrhage: patients who had a history or imaging findings of intracerebral hemorrhage in the past, or multiple cerebral microbleeds. A total of 1,512 patients were enrolled in the study, and the participants were randomly assigned to receive either cilostazol (200 mg per day) or aspirin (100 mg per day). The primary endpoints were time to event of a hemorrhagic stroke (safety), and composites of total stroke, myocardial infarction, and vascular death (efficacy). After a mean follow-up of two years, 63 composite vascular events occurred in the cilostazol group vs. 80 events in the aspirin group, indicating non-inferiority of cilostazol to aspirin. Regarding safety, eight hemorrhagic strokes occurred in the cilostazol group vs. 16 events in the aspirin group. Ischemic stroke occurred less in the cilostazol group than in the aspirin group, but myocardial infarction occurred more often in the cilostazol group than in the aspirin group. Because this study was conducted exclusively in an East Asian population, additional clinical trials will be needed in other populations to see if effects are similar or different depending on the ethnic group that is being studied.
Triple Antiplatelet Therapy and TIA
Philip Bath from Nottingham, United Kingdom, presented the results of the TARDIS trial, which compared intensive, triple antiplatelet therapy with U.K. guideline antiplatelet therapy for preventing the recurrence of acute ischemic stroke or TIA. Patients with acute non-cardioembolic ischemic stroke or TIA were randomized within 48 hours to intensive, triple antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole), or U.K. guideline antiplatelet therapy (clopidogrel alone, or combined aspirin and dipyridamole) given for one month. The primary outcome was stroke and/or TIA recurrence and stroke severity as measured by the modified Rankin scale at three months. The plan was to enroll 4,100 patients, but the independent data monitoring committee recommended stopping the trial after 3,096 patients had been enrolled. The baseline characteristics were a mean age of 69 years, 63% patients were male, ischemic stroke occurred in 70% of patients and TIA in 30% of patients, and the mean severity of ischemic stroke was an NIHSS of 4.0. The study was stopped because of a significant increase in major bleeding in the intensive antiplatelet therapy group (odds ratio, 2.49; P < 0.001). However, there was no difference in the numbers of stroke and TIA between the two groups when all stroke types were combined, including hemorrhagic and ischemic stroke. At three months, death occurred in 2% of the intensive therapy group and 1.9% in the standard therapy group, and the composite of stroke or major bleeding occurred in 7.1% and 6.8%, but none of these differences were significant. In summary, there was significantly more major bleeding in the intensive therapy arm, but no differences in benefits between the two treatment groups. Therefore, the recommendation is to continue to use single or dual antiplatelet therapy for prevention of recurrent stroke or TIA, per U.K. and U.S. guidelines.
These articles are based on the editor's personal interactions as a participant at the International Stroke Conference in Houston, Feb. 22-24, 2017. All interpretations and opinions are exclusively those of the editor.
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