MD Conference Express ISC 2013 - (Page 22)
CLINICAL TRIAL HIGHLIGHTS
The Secondary Prevention of Small
Subcortical Strokes Trial: Blood
Pressure Intervention Results
Written by Emma Hitt, PhD
Small subcortical strokes (S3), or lacunar strokes, account
for >25% of brain infarcts. Although S3 are the most
common cause of vascular dementia, no clinical trials
have focused on this stroke subtype. Oscar R. Benavente,
MD, University of British Columbia, Vancouver, Canada,
reported blood pressure (BP) intervention results from the
Secondary Prevention of Small Subcortical Strokes Trial
[SPS3; NCT00059306].
SPS3 enrolled 3020 patients who had experienced
lacunar strokes within 180 days, verified by MRI. The
median time from the index event to randomization
was 62 days. The mean patient age was 63 years, and
63% were male. Patients who had a cortical stroke,
cardioembolic disease, and/or carotid stenosis were
not eligible for the trial.
In the BP intervention portion of SPS3, patients were
randomized to a higher systolic BP (SBP) target of 130 to
149 mm Hg (higher target group, n=1519) or a lower SBP
target of <130 mm Hg (lower target group, n=1501).
Antihypertensives were not discontinued at study
entry, and BP medications were not specified by the
study protocol.
The primary outcome was recurrent stroke. During
a mean follow-up of 3.7 years, 277 first recurrent strokes
occurred. The secondary outcomes were major vascular
events, cognitive decline, or death.
The patients reached target BP at around 6 months.
At 1 year, the average SBP for the higher target group was
138 mm Hg compared with 127 mm Hg for the lower target
group. At the last observed visit, there was an average
difference in SBP between the groups of 11 mm Hg.
For the primary outcome, the lower target group
had an approximately 19% reduction in ischemic and
hemorrhagic strokes compared with the higher target
group, but this trend did not reach significance (HR,
0.81; 95% CI, 0.64 to 1.03; p=0.08). However, when
ischemic and hemorrhagic strokes were separated,
there was a significant reduction in intracerebral
hemorrhage in the lower versus the higher target group
(HR, 0.37; 95% CI, 0.15 to 0.95; p=0.03). The reduction
in ischemic strokes did not reach significance after
separating these events.
There were no significant differences between the
lower and higher target groups in the secondary outcomes
of major vascular events and death. The safety outcomes
between the 2 groups were not significantly different, but
22
April 2013
more patients in the lower target group had complications
due to hypotension (HR, 1.53; 95% CI, 0.80 to 2.93; p=0.20),
particularly orthostatic syncope (HR, 2.18; 95% CI, 0.76 to
6.27; p=0.14).
Prof. Benavente said, “Achieving a lower systolic
blood pressure target was feasible, safe, and well
tolerated.” An SBP of <130 mm Hg significantly reduced
intracerebral hemorrhage by two thirds, and a lower
BP is likely to reduce recurrent stroke by approximately
20%, even though this trend did not reach significance.
Although this is the only trial that has used target BP
levels as an intervention, the results are consistent with
data from previous trials of BP lowering after stroke.
Final Results of the Solitaire
FR Thrombectomy for Acute
Revascularization: The STAR Trial
Written by Muriel Cunningham
Vitor Mendes Pereira, MD, MSc, University Hospital
of Geneva, Geneva, Switzerland, presented the
results from the Solitaire FR Thrombectomy for Acute
Revascularisation trial [STAR; NCT01327989]. This was a
prospective, observational, single-arm, multicenter, core
lab-reviewed study conducted in high-volume stroke
centers that had extensive mechanical thrombectomy
experience. The Solitaire FR, a self-expanding retrievable
stent, was utilized as a first-intention device in
anterior circulation.
The main inclusion criteria were patients aged 18
to 85 years with a National Institutes of Health Stroke
Scale (NIHSS) score of 8 to 30, proximal anterior
intracranial vasculature, and presentation within 8
hours of the onset of stroke, with a modified Rankin
Scale (mRS) score ≤2 prior to stroke onset. Patients who
were participating in another study, were pregnant or
nursing, had signs of rapid neurological improvement,
suffered a stroke within the previous 30 days, had an
unknown time of stroke onset, or had a life expectancy
<90 days were excluded. Additionally, any patients with
evidence of intracranial hemorrhage, arteriovenous
malformation, aneurysm, early ischemic changes,
carotid dissection, complete carotid occlusions,
vasculitis, or stenosis proximal to the thrombus site
were excluded.
Of the 682 patients screened, 471 failed screening and
9 withdrew consent, for a total of 202 patients in the final
study population. The median age was 72 years (range, 25
to 86), with 122 (60%) females and 80 (40%) males. The
median NIHSS at baseline was 17 (range, 8 to 26). Stroke
and procedure characteristics are presented in Table 1.
www.mdconferencexpress.com
http://www.mdconferencexpress.com
Table of Contents for the Digital Edition of MD Conference Express ISC 2013
MD Conference Express ISC 2013
Contents
Defending the Stroke Guidelines
Stroke Update: An Overview of What Is Going on in the Area of Stroke
Brain Imaging Does Not Help Identify Patients Who May Benefit From Endovascular Treatments for Acute Ischemic Stroke
MISTIE II Trial: 365-Day Results Demonstrate Improved Outcomes and Cost Benefit
Addition of AMPLATZER PFO Occluder to Medical Therapy Is Beneficial in Patients With Cryptogenic Stroke and PFO
Intraoperative CT-Guided Endoscopic Surgery for ICH [ICES]
The EMBRACE Trial: Prolonged Ambulatory Cardiac Monitoring Improves the Detection and Treatment of Atrial Fibrillation in Patients With Cryptogenic Stroke
DP-b99 Does Not Improve Recovery Following Acute Ischemic Stroke
The Secondary Prevention of Small Subcortical Strokes Trial: Blood Pressure Intervention Results
Final Results of the Solitaire FR Thrombectomy for Acute Revascularization: The STAR Trial
Clopidogrel Plus Aspirin Reduces Risk of Recurrent Stroke: The CHANCE Trial
Reversal of Chronic Hypoperfusion to Improve Cognitive Function: The RECON Trial
Cardioembolic Stroke
IMS III
Novel Anticoagulants in Vascular Neurology Practice
Wake-Up Stroke
Virtual Reality in Stroke Rehabilitation
Reward Improves Long-Term Retention of a Motor Memory Through Induction of Offline Memory Gains
MD Conference Express ISC 2013
https://www.nxtbook.com/nxtbooks/md_conference_express/ISC2013
https://www.nxtbookmedia.com