Endovascular Stroke Treatment and Systems of Care

Mokin M, Snyder KV, Siddiqui AH, Levy EI, Hopkins LN.
Recent Endovascular Stroke Trials and Their Impact on Stroke Systems of Care. J Am Coll Cardiol 2016;67:2645-2655.

Recently, a number of trials were published showing improved outcomes for acute stroke patients treated with endovascular therapy. Mokin and colleagues summarized the trial results and discussed the implications for stroke systems of care. The following are seven key points to take away from this review article:

  1. Ischemic stroke caused by large vessel occlusion (LVO) is common and associated with poor functional outcomes.
  2. Recently published trials that randomized ischemic stroke patients with LVO to endovascular thrombectomy versus usual care (with both groups receiving intravenous tissue plasminogen activator [IV-rtPA], if eligible) showed that patients treated with endovascular thrombectomy had substantially improved functional outcomes. This was in contrast to earlier trials of endovascular thrombectomy that showed the procedure was ineffective. The contemporary trials were positive because of improved thrombectomy technology (stent retrievers) that led to better recanalization; an emphasis on rapid treatment; and patient selection using preprocedure vessel imaging, typically computed tomography angiography.
  3. Patients who are eligible for IV-rtPA should receive IV-rtPA and then be considered for endovascular thrombectomy.
  4. In the trials, most patients were treated within 6 hours from the last known normal time. The evidence of extending time windows beyond 6 hours is lacking. This means that stroke systems of care need to be able to promptly recognize and transfer patients eligible for endovascular thrombectomy to hospitals that offer this service.
  5. There are tremendous variations in stroke systems of care across the country. While there are parallels between stroke and ST-segment elevation myocardial infarction and trauma, because of the diversity and complexity of stroke patients and the lack of a clear diagnostic test for stroke, other models for systems of care do not always generalize to stroke.
  6. Recognition of stroke in the prehospital setting is important, and prehospital notification by the emergency medical system (EMS) reduces door-to-treatment times for patients treated with IV-rtPA. If patients with stroke due to LVO could be identified by EMS, they could be transported to hospitals that have endovascular capabilities, bypassing hospitals without these capabilities. Unfortunately, screening tools to evaluate for LVO lack sensitivity and specificity, limiting their use.
  7. Currently, performance standards for endovascular thrombectomy are limited. Additional measures, such as door-to-groin puncture, are needed so processes can be tracked, compared, and reported.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Aortic Surgery, Lipid Metabolism, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: Angiography, Cerebral Infarction, Diagnostic Imaging, Emergency Medical Service Communication Systems, Endovascular Procedures, Myocardial Infarction, Myocardial Ischemia, Stents, Stroke, Thrombectomy, Tissue Plasminogen Activator, Tomography, Treatment Outcome, Vascular Diseases

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