Quick Links

Share with Colleagues
Previous EBM Focus Issues
DynaMed Free Trial
Send Comment to Editor

Join Our Mailing List



Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: December 24, 2014
Expiration Date: December 24, 2015

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237G2

Last week 597 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 184 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Addition of Intra-arterial Treatment within 6 Hours of Stroke Onset to Usual Care Improves Functional Outcomes in Patients with Acute Ischemic Stroke Due to a Proximal Intracranial Occlusion of the Anterior Circulation

Reference: MR CLEAN trial (N Engl J Med 2014 Dec 17 early online) (level 1 [likely reliable] evidence)

Stroke is a major cause of death and disability worldwide, but administration of intravenous alteplase within 3-4.5 hours of symptom onset is currently the only recommended reperfusion therapy for patients with acute ischemic stroke (Stroke 2013 Mar;44(3):870, NICE 2012 Sep:TA264). Intravenous alteplase treatment has many contraindications, however, and its effectiveness may depend upon the location of the occlusion (JAMA 2004 Oct 20;292(15):1839, JAMA Neurol 2014 Feb;71(2):151). A recent randomized trial compared intra-arterial treatment plus usual care vs. usual care alone in 502 patients (mean age 65 years) with acute ischemic stroke due to proximal arterial occlusion in the anterior cerebral circulation.

All patients eligible for randomization had occlusion confirmed on vessel imaging and could be treated within 6 hours of stroke onset. Intravenous alteplase was allowed as part of usual care and 89% of patients received alteplase before randomization. Intra-arterial therapy consisted of arterial catheterization with a microcatheter to the occlusion plus delivery of a thrombolytic agent, mechanical thrombectomy (thrombus retraction, aspiration, wire disruption, or retrievable stent), or both. Actual intra-arterial therapy was only performed in 84.1% of the 233 patients randomized to this intervention, 96.9% of whom had mechanical treatment with retrievable stents. Intra-arterial thrombolytics were used in 10.3% of patients randomized to intra-arterial treatment, but only 1 patient received intra-arterial thrombolytics alone. Arterial recanalization was observed on imaging 24-hours after treatment in 75.4% in the intra-arterial treatment group vs. 32.9% in the usual care group (p < 0.05). At 90-days post-treatment, 32.6% of patients in the intra-arterial treatment group had a modified Rankin score of 0-2 compared to 19.1% of patients in the usual care group (adjusted odds ratio 2.16, 95% CI 1.39-3.38 NNT 8). Intra-arterial treatment was also associated with significantly more patients experiencing no disability interfering with daily activities at 90 days as measured by a score of 19-20 on the Barthel index (46% vs. 29.8%, p < 0.05 NNT 7). There were no significant differences between groups in any serious adverse events or mortality, however intra-arterial treatment was associated with an increased rate of new ischemic stroke at different vascular territory (5.6% vs. 0.4%, p < 0.001 NNH 19).

The results of this trial suggest that intra-arterial treatment may significantly improve functional outcomes in patients with acute ischemic stroke due to proximal arterial occlusion in anterior cerebral circulation. Previous randomized trials have found no significant improvement with intra-arterial therapy compared to intravenous alteplase alone (N Engl J Med 2013 Mar 7;368(10):904, N Engl J Med 2013 Mar 7;368(10):914, N Engl J Med 2013 Mar 7;368(10):893). However, the methodology of these trials varied considerably. One trial did not allow intravenous alteplase before endovascular treatment, instead using heparin during angiography, and using a micro-guidewire for clot disruption with few patients receiving retrievable stents (N Engl J Med 2013 Mar 7;368(10):904). Another smaller trial performed mechanical embolectomy with a coil retriever or aspiration device (N Engl J Med 2013 Mar 7;368(10):914), while the final trial mainly used these devices and did not have radiologically proven occlusions in all patients (N Engl J Med 2013 Mar 7;368(10):893). The retrievable stents used in the current trial have been shown to be more effective than Merci coil retrievers used in the previous trials (Lancet 2012 Oct 6;380(9849):1231, Lancet 2012 Oct 6;380(9849):1241). Rather than this trial contradicting earlier findings, it seems that this represents an improvement in the approach to intra-arterial therapy to the point where it now may become another component of the management of patients with acute stroke.

For more information, see the Endovascular therapy for acute stroke topic in DynaMed.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Oncology (especially Breast cancer, Head and neck cancer, Pancreatic cancer), Ophthalmology, Orthopedics, Pediatric Neurology, and Vascular.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

PEMSoft Mobile

Free Trial of PEMSoft Mobile Available For iPhone, iPad, and Android Devices

The PEMSoft Mobile app, a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools, is now available from EBSCO Health. Designed by pediatricians, emergency physicians and other medical specialists, the vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

Content in the PEMSoft Mobile app covers more than 3,000 conditions and includes a similar number of medical illustrations, clinical images and videos. PEMSoft Mobile also includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms, and topics covering pediatric injuries and management approaches.

Visit the PEMSoft Mobile App Trial page to access a free trial for both Apple and Android devices.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
Education for Clinicians in Training