The edition · Top Clinical Updates
Two NEJM stroke trials widen who may benefit from thrombectomy: mild deficits, and patients arriving up to 72 hours late
Thrombectomy in mild large-vessel stroke and beyond 24 hours, an oral GLP-1 drug's cardiovascular safety against insulin, childhood cancer after frozen embryo transfer and ICSI, and pre-eclampsia after living kidney donation.
The edition in brief
Two open-label Chinese trials in NEJM test thrombectomy outside its usual limits. MILD-MT randomised 300 patients with large-vessel anterior stroke, NIHSS under 6 and a large perfusion mismatch within 24 hours: excellent outcome (mRS 0–1) at 90 days was 69.4% with thrombectomy against 50.0% with medical care (OR 2.32), with no excess symptomatic haemorrhage but 13.2% serious procedural complications. LATE-MT randomised 336 patients with salvageable tissue at 24 to 72 hours: thrombectomy improved the 90-day disability distribution (common OR 1.74) but symptomatic haemorrhage was 4.8% against none and deaths 6.0% against 1.8%. Neither has yet changed guidelines. ACHIEVE-4 found the oral GLP-1 agonist orforglipron non-inferior to insulin glargine for major cardiovascular events in 2,749 people with type 2 diabetes and cardiovascular or kidney disease (HR 0.84, 0.59–1.20), with less hypoglycaemia and more gastrointestinal effects. A Danish cohort of over a million children associated frozen embryo transfer (HR 2.18) and ICSI (HR 1.48), but not conventional IVF, with childhood cancer; absolute rates stayed low. A Canadian matched cohort found living kidney donors had more hypertensive disorders of pregnancy afterwards (11.9% vs 8.3%; RR 1.51).
Thrombectomy 24 to 72 hours after stroke: better function, more haemorrhage and death
Consider urgent stroke-centre discussion for large-vessel stroke found up to 72 hours late, with the bleeding risk made explicit.
Orforglipron, an oral GLP-1 agonist, was non-inferior to insulin glargine for cardiovascular events
An oral GLP-1 agonist passed its cardiovascular safety test against insulin, with less hypoglycaemia and more nausea.
Frozen embryo transfer and ICSI, but not conventional IVF, linked with childhood cancer
Counsel couples that some fertility techniques were associated with a small absolute rise in childhood cancer.
Hypertensive disorders of pregnancy were more common after living kidney donation
Treat a previous living kidney donation as a reason for closer blood-pressure and growth monitoring in pregnancy.
Last known well, not time found, starts the stroke clock
Write down last-known-well time and the witness at first contact with any stroke patient.
Thrombectomy in mild large-vessel stroke: excellent outcome 69% versus 50%
Consider urgent stroke-centre referral for mild stroke with a large-vessel occlusion and a large perfusion mismatch.
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