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What is the prognosis of mild and severe stroke?

What is the prognosis of mild and severe stroke?. ESC, Lisbon, May 23 rd 2012. Eivind Berge Oslo University Hospital. What is the natural course of mild and severe strokes? What is the effect of rt-PA on the course of mild and severe strokes?.

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What is the prognosis of mild and severe stroke?

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  1. What is the prognosis of mild and severe stroke? ESC, Lisbon, May 23rd 2012 Eivind Berge Oslo University Hospital

  2. What is the natural course of mild and severe strokes? What is the effect of rt-PA on the course of mild and severe strokes? «What is the prognosis of mild and severe stroke?»

  3. Mild strokes: Should they be treated with rt-PA? No: Mild strokes have of «low chance of benefit» and have not been studied in clinical trials Yes: «Mild» strokes are not always mild strokes Yes: Observational studies have indicated similar-sized effects of rt-PA in mild stroke1,2 1Mishra NK. Stroke 2010;41:2612 2Saposnik G. Stroke 2012;43:1315

  4. Severe strokes: Should they be treated with rt-PA? No: Severe strokes have «high risk of harm» and have not been studied in clinical trials No: Observational studies have indicated lower effects of rt-PA in severe stroke1 RR 1Saposnik G. Stroke 2012;43:1315 Stroke severity (iScore)

  5. Severe strokes: Should they be treated with rt-PA? No: Severe strokes have «high risk of harm» and have been excluded from clinical trials Yes: Other studies have indicated similar-sized effects in severe strokes1,2 NIHSS score 1Mishra NK. Stroke 2010;41:2612 2Ingall TJ. Stroke 2004;35:2418

  6. NIHSS score (neurological deficits) OCSP class (stroke syndrome) Predicted probability of poor outcome at 6 months1 Markers of «mild» and «severe» stroke in IST-3 1König IR, et al. Stroke 2008;39:1821

  7. Measure of prognosis in IST-3 • Proportion of patients «alive and independent» at 6 months (OHS/mRS 0-2)

  8. Proportion «alive and independent» at 6 months in control group

  9. Proportion «alive and independent» at 6 months in control group

  10. Proportion «alive and independent» at 6 months in control group

  11. Effect of rt-PA on the proportion «alive and independent» at 6 months

  12. Effect of rt-PA on the proportion «alive and independent» at 6 months

  13. Effect of rt-PA on the proportion «alive and independent» at 6 months

  14. Effect of rt-PA on the proportion «alive and independent» at 6 months

  15. Summary: Prognosis of mild and severe strokes • «Mild» strokes are not always mild, and «severe» strokes are almost always severe • There was no clear evidence of a differential effect of rt-PA in mild or severe strokes • There was a trend towards a better effect in severe stroke, even after adjustment for key prognostic variables

  16. Implications for practice and research • There is no reason to routinely withhold rt-PA from mild or severe strokes • «Mild» strokes are not always mild, and are likely to benefit from treatment • «Severe» strokes have a very poor prognosis if left untreated, and are very likely to benefit • The PRISMS trial is being planned in the US to determine the effect of rt-PA in mild strokes (NIHSS score ≤ 5)

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