Acute Endovascular Therapy for Stroke | Ten Points to Remember
- Khatri P, Hacke W, Fiehler J, et al., on behalf of the VISTA-Endovascular Collaboration.
- State of Acute Endovascular Therapy: Report From the 12th Thrombolysis, Thrombectomy, and Acute Stroke Therapy Conference. Stroke 2015;May 5:[Epub ahead of print].
The following are 10 points to remember from the 12th Thrombolysis, Thrombectomy, and Acute Stroke Therapy Conference report about the state of acute endovascular therapy:
- Acute endovascular therapy for ischemic stroke is at a pivotal juncture.
- Initial trials in 2013 used intra-arterial thrombolysis, or first-generation devices, with little use of newer-generation devices, such as stent retrievers, which were found to achieve significantly higher rates of recanalization and failed to demonstrate improved clinical outcomes.
- Over a landmark 5-month recent period, four successive, randomized trials have together unequivocally shown the benefit of endovascular therapy for selected patients with acute ischemic stroke.
- The recently presented and published trial results allow the field to progress from asking whether endovascular therapy is clinically beneficial to asking who will benefit from endovascular therapy.
- We need to determine the generalizability of these recent trial findings, including how to apply them in varied healthcare structures across the world, while maintaining similar or better risk-benefit ratios.
- Pooled analyses of available studies will play a critical role in advancing the field.
- The three previously completed (IMS III, SYNTHESIS, and MR RESCUE) and all 13 recently completed or ongoing endovascular trials with intravenous recombinant tissue-type plasminogen activator (r-tPA)–treated subjects have committed to a retrospective patient-level pooled analysis of randomized trials testing combined intravenous r-tPA/endovascular versus intravenous r-tPA alone, entitled the Thrombectomy and tPA (TREAT) analysis.
- The primary data pool for the TREAT analysis will consist of subjects enrolled in prospective, randomized trials with newer-generation devices (direct aspiration catheters or stent retrievers) comprising at least 85% of treated cases, and sensitivity analyses will be performed by including trials using older-generation devices.
- The TREAT analysis will test whether key patient selection criteria modify treatment effect. Specifically, it will test whether the following variables modify treatment effect: location of intracranial arterial occlusion (intracranial internal carotid artery vs. M1 vs. M2 vs. A1/A2), stroke severity (baseline National Institutes of Health Stroke Scale), time to initiation of intravenous r-tPA and randomization, early ischemic changes on baseline neuroimaging, and age.
- These analyses will advance our understanding of optimal patient selection criteria for endovascular therapy in daily clinical practice, and will allow appropriate planning for future clinical trials to further enhance outcomes after acute ischemic stroke.
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