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Tranexamic Acid for Prevention of Hematoma Expansion in Intracerebral Hemorrhage Patients With or Without Spot Sign

Prior trials of hemostatic agents in patients with intracerebral hemorrhage have not been associated with improved functional outcomes. In this prespecified subgroup analysis of the TICH-2 trial (Tranexamic Acid for Hyperacute Intracerebral Haemorrhage), investigators hypothesized that patients with intracerebral hemorrhage and spot sign, who are at high risk of hematoma expansion, may benefit from tranexamic acid relative to patients without the spot sign. A total of 245 patients were included in the study with similar baseline characteristics to the original TICH-2 cohort, except the time from onset to administration of the trial drug was shorter in those who underwent computed tomography angiography or contrast-enhanced computed tomography. Overall, there was no difference in hematoma progression between the tranexamic acid group and the placebo group. Similarly, there was no difference in adverse events or functional outcomes at 90 days between the 2 groups. The investigators were, therefore, unable to demonstrate that the presence of a spot sign impacted the response to tranexamic acid versus placebo in patients with intracerebral hemorrhage. These results, however, are limited in the setting of a small, underpowered sample size. Similar to prior trials in which administration of the hemostatic agent was delayed, delays in administering tranexamic acid after identifying a spot sign (median time 76 minutes) may have impacted the overall results and limited the extent to which hematoma expansion could have been prevented. Further research is needed to assess whether very early administration of hemostatic agents in the presence of a spot sign would be beneficial in preventing hematoma expansion and improving functional outcomes in patients with intracerebral hemorrhage. See p 2629.

Deintensification or No Statin Treatment Is Associated With Higher Mortality in Patients With Ischemic Stroke or Transient Ischemic Attack

The benefit of statins for secondary stroke prevention in patients with atherosclerotic disease has been well established. In this observational study, investigators identified the effect of various statin treatment patterns on mortality after stroke and transient ischemic attack using pharmacy data across the Veterans Health Administration hospitals in the United States. In this cohort of 9380 patients (predominantly white males), 51% were not on statin at hospital admission, and 34% were not discharged on a statin after stroke or transient ischemic attack. Deintensification of statin therapy at hospital discharge occurred in 14% and 21% had no statin at admission and discharge. Compared with patients at goal for statin therapy at hospital discharge, deintensification of statin therapy was associated with 1.6 greater odds of 30-day mortality (95% CI, 1.06–2.41) and 1.26 greater odds of 1-year mortality (95% CI, 1.02–1.57). Patients who were discharged after stroke or transient ischemic attack without statin therapy had a 2-fold increased risk of 30-day mortality (95% CI, 1.42–2.82) and 1.6-fold higher risk of 1-year mortality (95% CI, 1.30–1.93). Interestingly, patients in the no statin group or statin deintensification group had less chronic comorbidities and less severe stroke, yet the study results remain similar after multivariable adjustment. This study not only confirms the benefit of statin therapy after stroke but also raises awareness on statin underutilization in the real-world setting and the potentially devastating effect on patient outcomes. See p 2521.

Access to Mechanical Thrombectomy for Ischemic Stroke in the United States

Although endovascular therapy (EVT) has become standard of care for large vessel occlusion stroke, timely access to a comprehensive stroke center that can provide EVT and post-EVT stroke care may vary geographically. In this study, investigators used a large all-payer claims database to characterize access to EVT across 11 states in the United States, characterizing centers as a thrombectomy hub if they perform EVT, a thrombectomy gateway if they transferred patients to a thrombectomy hub, and a thrombectomy gap if they neither performed nor transferred patients for EVT. Patients initially treated at thrombectomy hubs comprised 48.7% of the cohort, of which 4.8% underwent thrombectomy. Those initially presenting to thrombectomy gateways were significantly less likely to undergo thrombectomy compared with patients at thrombectomy hubs. Furthermore, 16% of the stroke cohort was initially treated at a thrombectomy gap, where EVT or transfer to an EVT facility was not offered. Not surprisingly, patients living in rural locations were significantly more likely to be treated at a thrombectomy gap hospital compared with patients living in more urban areas. Even in urban locations, however, roughly one-third of the population did not have speedy access to a thrombectomy hub. Overall, <50% of patients included in the study with acute ischemic stroke presented to a thrombectomy hub from 2016 to 2018. This study highlights the geographic disparities that exist in access to standard of care for large vessel occlusion stroke, obviating the need for optimizing stroke systems of care in the US to provide equal and timely access to thrombectomy regardless of geographic region. See p 2554.

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