In the News

PEG placement after acute stroke, thrombolysis in stroke, and more.

Model may help predict PEG placement after acute stroke

A new model may help predict percutaneous endoscopic gastrostomy (PEG) placement after acute stroke.

Researchers used retrospective data in patients with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) to develop prediction scores for PEG placement. Patients were admitted consecutively to a single academic stroke center from July 2008 to December 2010. Those who had a stroke in the hospital, those who were transferred from an outside facility, those with an unknown “last seen normal” time, those with another cause or reason for their dysphagia besides stroke, and those who presented 24 hours after last being seen normal were excluded. Data on demographics, clinical characteristics and outcome measures were taken from the medical record. The study results were published in the November Stroke.

Both scores had a maximum of 5 points. For the AIS-PEG score, 1 point each was given for age 80 years or older, 24-hour National Institutes of Health Stroke Scale (NIHSS) score of 8 to 14, black ethnicity, and an infarct involving the cortex; an extra point was given if the NIHSS score was above 14. For the ICH-PEG score, 1 point each was given for black ethnicity, 24-hour NIHSS score of 8 to 14, a midline shift (defined as >3 mm) on the first computed tomography scan of the head, and edema on follow-up computed tomography of the head; again, an extra point was given if the NIHSS score was above 14.

Four hundred seven patients were included in the study, and of these 51 (12.5%) received PEG placement while in the hospital. Twenty-five patients in the latter group had acute ischemic stroke, and 26 had intracerebral hemorrhage. Patients who had an AIS-PEG score of 3 or above and those who had an ICH-PEG score of 3 or above were more likely to receive a PEG than those with an AIS-PEG score or ICH-PEG score less than 3 (odds ratios, 15.68 [95% CI, 4.55 to 54.01] and 12.49 [95% CI, 1.54 to 101.29], respectively).

The authors noted that their study was small and involved 1 academic medical center. However, they concluded that the scores they developed can help physicians estimate which patients will need PEG placement during hospitalization. “With the expedited placement of a PEG, enteral nutrition can be initiated and the risks of malnutrition, prolonged length of stay, and mortality could be minimized,” they wrote.

Thrombolysis could lead to poor outcomes in certain stroke patients

Patients with acute ischemic stroke and infective endocarditis may have worse outcomes after thrombolysis, according to a recent study.

Researchers used data from the Nationwide Inpatient Sample to examine outcomes in patients with acute ischemic stroke and infective endocarditis who were treated with intravenous thrombolysis from 2002 to 2010. The main outcome measures were post-thrombolytic intracerebral hemorrhage and favorable outcomes. Study results were published in the October Stroke.

Overall, 222 patients with acute ischemic stroke and infective endocarditis and 134,048 patients with acute ischemic stroke and no infective endocarditis received thrombolysis. Patients who had infective endocarditis had a significantly higher rate of post-thrombolytic intracerebral hemorrhage compared with those who did not have infective endocarditis (20% vs. 6.5%; P=0.006) and were significantly less likely to have a favorable outcome (10% vs. 37%; P=0.01). Hospital stay was significantly longer and hospital charges were higher in the infective endocarditis group.

“In the absence of a randomized comparison between thrombolytic and nonthrombolytic treatment among [these patients], thrombolytic treatment cannot be prohibited in this group of patients,” the authors wrote. However, they concluded, the high rate of intracerebral hemorrhage and low rates of favorable outcome observed in their study warrant caution, including “careful risk-benefit analysis on a case-by-case basis.”

Study of dabigatran with mechanical heart valves halted

Dabigatran caused more thromboembolic and bleeding complications than warfarin in patients with mechanical heart valves, according to a study that was prematurely halted as a result.

The phase II, manufacturer-sponsored study included patients who had undergone aortic- or mitral-valve replacement either within a week prior to drug initiation or more than 3 months earlier. They were randomly assigned to warfarin (adjusted to obtain an international normalized ratio of 2 to 3 or 2.5 to 3.5 depending on thromboembolic risk) or dabigatran (an initial dose of 150, 220 or 300 mg twice daily based on kidney function). Results were published in the Sept. 26 New England Journal of Medicine.

The study was halted after enrollment of 252 patients, 162 of whom were treated with dabigatran. Fifty-two of those patients required adjustment or discontinuation of their dabigatran dose. More dabigatran patients than warfarin patients had ischemic or unspecified strokes (5% vs. zero) or major bleeding (4% vs. 2%, all pericardial bleeds). The study authors concluded that the drug showed no benefit and excess risk compared to warfarin.

They noted that most thromboembolic events occurred in the dabigatran group who started the drug within a week of surgery. The higher risk of thromboembolism might be due to inadequate plasma levels of the drug (although higher levels might have led to even more bleeding complications) or the difference in the 2 treatments' mechanisms of action (because dabigatran is less able to suppress coagulation resulting from exposure to artificial surfaces). The results show that dabigatran is not an acceptable alternative to warfarin for this indication and that the effectiveness of factor Xa inhibitors at preventing strokes in patients with atrial fibrillation should not be extrapolated to patients with mechanical valves, the authors concluded.