- N Engl J Med 2022; 386:1560-1570
A 41-year-old woman with transient dysarthria and facial droop was evaluated for mitral valve masses. Three weeks earlier, she had heavy vaginal bleeding with crampy abdominal pain, fatigue, and lightheadedness. CT imaging was notable for small chronic cerebral infarcts and uterine fibroids. Diagnostic test results were received, and management decisions...
- N Engl J Med 2022; 386:1359-1361
In this issue of the Journal, Yoshimura and colleagues1 report the favorable results of a well-conducted randomized trial comparing mechanical thrombectomy (endovascular therapy) with medical care in patients with large-vessel occlusion and large cerebral infarctions. Previous trials of endovascular therapy in selected populations of patients with...
- N Engl J Med 2022; 386:1351-1351
A 63-year-old man presented with weakness on the left side and difficulty speaking, both of which had begun 6 hours earlier. Imaging revealed a complete occlusion of the right internal carotid artery. He received emergency endovascular therapy.
- N Engl J Med 2022; 386:1303-1313
Endovascular therapy for stroke is generally avoided if the cerebral infarction is large. In a trial conducted in Japan, the percentage of patients who had a good functional outcome at 90 days was higher with endovascular therapy than with medical care, but there were more cerebral hemorrhages with endovascular therapy.
- N Engl J Med 2021; 385:2520-2530
In a trial in China, patients with a minor stroke or transient ischemic attack with CYP2C19 loss-of-function alleles as determined by point-of-care testing had modestly fewer second strokes with ticagrelor than with clopidogrel but also had more total bleeding events.
- N Engl J Med 2021; 385:2563-2572
A 9-year-old boy was transferred to this hospital because of transient weakness, facial droop, and slurred speech that occurred after an episode of crying. The symptoms lasted approximately 2 minutes and then resolved. Two years earlier, the patient had been evaluated for episodes of shaking in the arms and legs....
- N Engl J Med 2021; 385:2576-2577
The late 20th and early 21st centuries have seen a reduction in stroke risk resulting from lifestyle changes such as widespread smoking cessation and more regular exercise, advances in the treatment of hypertension and hyperlipidemia, and better control of the vascular complications of diabetes.1 Antiplatelet agents have played...
- N Engl J Med 2021; 385:1904-1905
In the past few years, thrombectomy — the removal of a thrombus under angiographic guidance — has become an accepted treatment for acute ischemic stroke caused by occlusion of a large cerebral vessel.1 Guidelines have included the use of intravenous alteplase preceding thrombectomy1 if there are...
- N Engl J Med 2021; 385:1833-1844
Trials involving Asian patients with acute stroke have suggested that endovascular treatment alone is not inferior to the usual practice of thrombolysis before endovascular treatment. This trial involving European patients did not show noninferiority or superiority of endovascular treatment alone.
- N Engl J Med 2021; 385:1043-1044
In their article in this issue of the Journal on emergency medical response in cases of stroke, Grotta and colleagues1 report several positive findings for mobile stroke units in comparison with conventional medical service ambulances. These include 22% greater access to intravenous thrombolysis treatment with mobile...
- N Engl J Med 2021; 385:971-981
Mobile stroke units have CT scanners and personnel trained to administer tissue plasminogen activator. In a multicity trial, functional outcomes at 90 days after acute stroke were better with mobile stroke units than with standard care by emergency medical services and transfer to an emergency department.
- N Engl J Med 2021; 384:1954-1955
The benefits of endovascular therapy provided soon after the onset of acute ischemic stroke due to large-vessel occlusion in the proximal anterior cerebral circulation were established by five clinical trials, the results of which were published in 2015.1 The DAWN (DWI or CTP Assessment with Clinical Mismatch in...
- N Engl J Med 2021; 384:1910-1920
In a randomized trial involving 300 patients with basilar-artery stroke, endovascular thrombectomy was not significantly different from medical therapy with respect to a favorable functional outcome (modified Rankin scale score of 0 to 3) at 90 days, but a clinically significant benefit could not be excluded.
- N Engl J Med 2021; 384:970-971
In the initial report of the Gore REDUCE trial of patent foramen ovale closure, with a median follow-up of 3.2 years, 18 patients had stroke recurrence (6 in the PFO closure group and 12 in the antiplatelet-only group). After a median follow-up of 5 years, 20 patients had stroke recurrence,...
- N Engl J Med 2020; 383:207-217
A trial involving 11,016 patients showed that the combination of ticagrelor and aspirin after a stroke or high-risk transient ischemic attack was better than aspirin alone in preventing a stroke or death within 30 days. Severe bleeding was rare but occurred more frequently in the dual antiplatelet group.
- N Engl J Med 2020; 383:252-260
Treatment for patients with acute ischemic stroke is guided by the time from the onset of stroke, the severity of neurologic deficit, and findings on neuroimaging. Recommended treatments in selected patients include intravenous thrombolysis with alteplase and mechanical thrombectomy.
- N Engl J Med 2020; 383:276-278
Without urgent treatment, the risk of major stroke in the week after a transient ischemic attack (TIA) or minor stroke can be as high as 10%.1 Some studies have shown that immediate medical treatment with antiplatelet agents and statins, as well as blood-pressure control, reduces that risk by...
- N Engl J Med 2020; 382:2316-2326
Endovascular thrombectomy has been effective in reducing stroke-related disability in high-income countries. This trial in the public health care system of Brazil, a developing country, showed similar effectiveness in patients treated within 8 hours after the onset of symptoms.
- N Engl J Med 2020; 382:1981-1993
In a multicenter Chinese trial involving 656 patients with large-vessel occlusion, endovascular thrombectomy was noninferior, within a 20% margin of confidence, to endovascular thrombectomy with intravenous alteplase given within 4.5 hours after stroke. The incidence of intracerebral hemorrhage was similar in the two groups.
- N Engl J Med 2020; 382:2045-2046
Endovascular thrombectomy has been shown to be safe and effective for the treatment of appropriately selected patients with acute ischemic stroke up to 24 hours after symptom onset.1-3 Several trials are attempting to expand the selection criteria for thrombectomy, in the hope of finding additional populations of patients...