Endovascular Treatment of Stroke — A Dramatic Reversal

Year in Review |
December 30, 2015

Endovascular Treatment of Stroke — A Dramatic Reversal

  1. Allan S. Brett, MD

In five trials, a new-generation device lowered rates of disability at 90 days.

  1. Allan S. Brett, MD

In three studies published in 2013, endovascular treatment of stroke with early-generation devices yielded no improvement in outcomes. But in 2015, results of five randomized trials that involved nearly 1300 patients convincingly resurrected endovascular stroke therapy. Use of new-generation “stent retrievers” generally are credited for this reversal.

Although inclusion criteria for the five trials differed slightly, enrolled patients were functionally independent prior to the stroke, sites of arterial occlusion were the intracranial internal carotid or proximal middle cerebral artery, endovascular intervention was feasible within 6 hours from stroke onset, and most patients received tissue plasminogen activator. All patients were assigned randomly to receive either endovascular treatment or no additional treatment. Retrievable stents were used in nearly all cases; these stents expand within the clot and then are withdrawn, pulling the clot along with them.

An outcome recorded in all trials was the proportion of patients with modified Rankin scores of 0–2 at 90 days (scores in this range indicate functional independence). In each trial, this favorable outcome occurred significantly more often in the endovascular-treatment groups than in the control groups:

Mortality was lowered in one trial.

Recognizing that these results define a new evidence-based intervention for selected stroke patients, the American Heart Association and American Stroke Association already have updated their guideline. The guideline's class I, level A recommendations endorsing endovascular therapy with stent retrievers are limited to adults whose clinical characteristics would have made them eligible for at least two of the five trials. The guideline suggests that endovascular intervention “may be reasonable” for some patient subgroups who do not meet class I criteria (e.g., patients with strokes in other arterial locations), but those are weaker recommendations (NEJM JW Neurol Sep 2015 and Stroke 2015; 46:3020).

The challenge now is to develop systems of regional stroke care that can deliver endovascular intervention in a timely fashion. Keep in mind, however, that only a small proportion of strokes — about 10% by an editorialist's estimate — will be suitable for endovascular intervention (NEJM JW Neurol Jun 2015 and N Engl J Med 2015; 372:2347).

Editor Disclosures at Time of Publication

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose

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