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Critical Care Medicine

Notes from the Chair

Evie G. Marcolini MD, FACEP, FAAEM
Chair, ACEP Critical Care Medicine Section

EvieMarcoliniThis is an exciting and dynamic time for the world of stroke and emergency medicine. At the recent International Stroke Conference, three new studies were revealed that confirm and extend the results of MR CLEAN1, demonstrating that mechanical clot removal after IV t-PA nearly doubles the rate of good outcomes (modified Rankin score 0-1) compared with IV t-PA alone.

This paradigm shift in stroke care has been anticipated by many since the publication of the IMSIII, SYNTHESIS, and MR RESCUE trials in 2013,2 which showed no improvement in outcome with endovascular therapy after t-PA for acute stroke. At that point in time, there was a question of equipoise, since most patients who consented for t-PA were likely to want interventional therapy, and wouldn’t want to be randomized, thus taking the chance on missing an opportunity.

Then MR CLEAN came along in January, showing that intra-arterial treatment after t-PA is safe. And now with EXTEND IA,3 ESCAPE,4 and SWIFT PRIME,5 we have evidence that IV t-PA followed by intra-arterial therapy improves outcome in select populations. The question left to be answered remains: what about intra-arterial therapy without t-PA?

That study has yet to be done, and may further change the way that we treat stroke patients in the emergency department. But for now, it is incumbent on us to pay attention to developments in the t-PA world.

The ACEP Clinical Policies Committee has revised the 2012 clinical policy for the use of IV t-PA for the management of acute ischemic stroke in the emergency department. This revision has created a stir in the worlds of emergency medicine, neurocritical care, and stroke.

The revision coincides with changes in the ACEP clinical policies development process. The subcommittee, under the clinical policies committee, has put the new draft document on the ACEP website for public review and comment until March 13th. This open policy of public commentary on drafts is new and will be going forward with all clinical policies.

The question of IV t-PA effectiveness for acute ischemic stroke in the ED has generated prolific literature, public opinion and controversy. We owe it to our patients and ourselves (we will be patients someday!) to understand the evidence and to build the best possible policy for a disease that has high incidence and prevalence as well as devastating effects on quality of life.

Regardless of how this pans out with future trials of endovascular therapy without t-PA, we owe it to our patients to weigh in on the guidelines for this complicated and critical issue.


  1. Berkhemer OA, Fransen PS, Beumer D, A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11-20.
  2. Chimowitz MI. Endovascular treatment for acute ischemic stroke--still unproven. N Engl J Med 2013;368:952-55.
  3. Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med 2015; Feb 11 (epub ahead of print)
  4. Goyal M, Demchuk AM, Menon BK, et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. N Engl J Med 2015; Feb 11 (epub ahead of print)
  5. http://www.medscape.com/viewarticle/839623



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