COMMENTARY

European Stroke Conference 2010

Mark J. Alberts, MD

Disclosures

June 22, 2010

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Mark J. Alberts, MD: Hello. My name is Dr. Mark Alberts. [I am] Professor of Neurology and Director of the Stroke Program at Northwestern University in Chicago.

Welcome to this Medscape Video Blog Stroke Update. For this update, I would like to share with you some recent studies presented at the European Stroke Conference held in Barcelona [Spain] in May.

One of the studies I want to talk about is the VITATOPS study.[1] This was a prospective randomized trial of about 8100 patients with a recent TIA [transient ischemic attack] or stroke and elevated homocysteine. They were randomized to receive a multivitamin preparation, B6, B12, and folate vs placebo. The primary endpoint was the occurrence of the composite of stroke, MI [myocardial infarction], or vascular death. Over 8000 patients were randomized and followed for almost 3½ years. At the end of the study what was found was an absolute risk reduction of 1.6% in favor of multivitamin therapy compared to placebo; however, this was a borderline significance with a P value of .05.

The result was presented by Dr. Graham Hankey from Perth, Australia. He subsequently did a meta-analysis including this study and all of the other studies looking at multivitamin therapy to prevent subsequent ischemic strokes in patients with a TIA or stroke. What they basically found is that in this meta-analysis there was no statistically significant difference in favor of multivitamin therapy vs placebo.

Where do we stand at the end of the day? We have a large study of equivocal significance in favor of multivitamin therapy and then we have other studies, some of which show a benefit and some of which don't show a benefit. What I tend to do in my practice, since all of the studies at least for stroke patients have suggested that multivitamin therapy is safe, is I do tend to give it because many of these patients also have B12 deficiency or folate deficiency. We also know that multivitamin therapy is very successful at reducing homocysteine levels. With this new study showing borderline significance, I'm still probably in favor of treating these patients with multivitamin therapy, particularly if their homocysteine level is quite high.

The other study I want to share with you is results from the SITS-MOST registry, which is a European registry that looked at the use of IV [intravenous] tPA [tissue plasminogen activator].[2] Since the more routine use of tPA is in the 3- to 4½-hour time window, SITS-MOST presented results about the efficacy and safety of IV tPA in this expanded time window and basically what they found is that the efficacy is somewhat comparable to what was reported in the ECASS 3 study, and the bleeding rates again were somewhat comparable to what was reported in the ECASS 3 study.

Looking at all the data together it's clear that getting tPA beyond the 3-hour time window is safe and effective, although its safety and efficacy is a little bit diluted compared to giving it within the 3-hour time window. Again the message with IV tPA continues to be time is brain, and whether you're going to adhere to a 3-hour time window or a 4½-hour time window, the idea is to give it as soon as possible and to reduce that door to needle time and onset to needle time to assure that the interval is possible.

Thank you very much for joining me for this Video Blog Stroke Update.

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