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    SMART stroke study improves patient access to lifesaving therapies

    March 17, 2016 (San Francisco, CA)

    Time is of the essence for treating acute ischemic stroke (AIS) and preventing permanent damage to the brain. The only FDA-approved drug for acute ischemic stroke is recombinant tissue plasminogen activator (rt-PA/thrombolytic therapy), administered intravenously.

    Pioneering research at CPMC determined that current criteria for thrombolytic therapy to treat AIS are unnecessarily complex. “The SMART (Simplified Management of Acute Stroke using Revised Treatment Criteria) approach is a new method enabling physicians to quickly and efficiently determine which patients will benefit from thrombolytic treatment,” says Nobl Barazangi, MD, PhD, a neurologist and Director of the CPMC Stroke and Neurocritical Care Research and Education Program at CPMC’s Comprehensive Stroke Care Center. “This approach significantly reduces the number of barriers by eliminating unnecessary exclusion criteria to administering thrombolytic therapy, while maintaining safety and efficacy of treatment.”

    Nationally, fewer than five percent of patients with AIS receive lifesaving thrombolysis (using the clot-busting drug, rt-PA), one of the most effective and accessible treatments available for stroke. At CPMC—home to one of the best stroke care and research programs in the U.S.—that rate averages over 25%, one of the highest rates nationwide.

    New research by CPMC’s stroke team was published last month in the Journal of Stroke and Cerebrovascular Diseases. Dr. Barazangi, David Tong, MD, Director of the CPMC Comprehensive Stroke Care Center, research fellow Sigrid B. Sørensen, MD, and colleagues showed that expanding the use of the SMART approach to outlying ‘spoke’ hospitals (including rural/ community hospitals) in addition to comprehensive stroke care centers such as CPMC results in good neurologic outcome at discharge and low complication rates.

    The retrospective study of more than 500 AIS patients treated over four years produced results comparable to those reported in randomized controlled trials. Rates of intracranial hemorrhage—a complication of thrombolytic therapy—were low.

    “We believe this study shows that the SMART criteria may be used broadly and not just at stroke centers, may help increase treatment for acute ischemic stroke nationally, and will hopefully encourage dialogue in the stroke community to revise the current rt-PA criteria,” says Dr. Barazangi.

    In a separate study, stroke researchers at CPMC showed that stroke patients transferred from large referral centers can benefit from stent retriever devices.

    Billy Gao, MD, Nobl Barazangi, MD, PhD, Joey English, MD, PhD and colleagues in CPMC’s Comprehensive Stroke Care Center presented new research at the 2016 International Stroke Conference last month on the safety and efficacy of stent retrievers in acute ischemic stroke (AIS) patients transferred from a large referral network.

    In the study, intra-arterial therapy using these stent retriever devices performed on transferred patients at a large comprehensive stroke center (May 2012-Jan 2015) was retrospectively reviewed.

    The primary outcome was 90-day modified Rankin Scale (mRS, a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke). The primary safety endpoint was symptomatic intracerebral hemorrhage (sICH). Secondary endpoints included successful reperfusion and mortality.

    Of the 90 patients who were treated, results suggested that—despite highly delayed stroke onset to treatment times—a transfer-based, CT perfusion-guided stent retriever treatment approach was feasible, safe, and effective.

    “A substantial proportion of transfer patients can receive successful intra-arterial therapy using these modern selection techniques,” said Dr. Barazangi, Director of CPMC’s Stroke and Neurocritical Care Research and Education Program.

    “With our pioneering use of stent retrievers, outcomes at CPMC are similar or even superior to those of published randomized trials in terms of reductions in post-stroke disability and low rates of symptomatic intracerebral hemorrhage.”