Stroke Treatment Academic Industry Roundtable (original) (raw)
Related papers
Endovascular Approaches to Acute Stroke, Part 2: A Comprehensive Review of Studies and Trials
American Journal of Neuroradiology, 2009
Reperfusion remains the mainstay of acute ischemic stroke treatment. Endovascular therapy has become a promising alternative for patients who are ineligible for or have failed intravenous (IV) thrombolysis. The conviction that recanalization of properly selected patients is essential for the achievement of good clinical outcomes has led to the rapid and widespread growth in the adoption of endovascular stroke therapies. However, comparisons of the recent reperfusion studies have brought into question the strength of the association between revascularization and improved clinical outcome. Despite higher rates of recanalization, the mechanical thrombectomy studies have demonstrated substantially lower rates of good outcomes compared with IV and/or intra-arterial thrombolytic trials. However, such analyses disregard important differences in clot location and burden, baseline stroke severity, time from stroke onset to treatment, and patient selection in these studies. Many clinical trials are testing novel devices and drugs as well as the paradigm of physiology-based stroke imaging as a treatment-selection tool. The objective of this article is to provide a comprehensive review of the relevant past, current, and upcoming data on endovascular stroke therapy with a special focus on the prospective studies and randomized clinical trials. R.G.N. is a member of the physician advisory boards and speaker bureau for Concentric Medical, ev3 Neurovascular, and Coaxia. He is also a member of the steering committee of the RETRIEVE trial and the principal investigator for the DAWN trial. J.A.H. is a member of the steering committee of the MERCI Registry.
Current Recommendations for Endovascular Interventions in the Treatment of Ischemic Stroke
Current Atherosclerosis Reports, 2010
Ischemic stroke remains one of the leading cause of adult death and disability in the United States. Reperfusion of the occluded vessel is the standard of care in the setting of acute ischemic stroke according to established guidelines. Since the introduction of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) in the late 1990s, significant advances have been made in methods to deliver thrombolytic agents and in devices for mechanical recanalization of occluded vessels. Furthermore, improvements in patient selection contribute to achievement of good clinical outcomes after endovascular therapy. This article summarizes findings from recent clinical trials and presents evidence-based guidelines for endovascular interventions in the treatment of ischemic stroke.
Endovascular Therapy for Acute Ischemic Stroke: Time to Enter a New Era in Stroke Management
2015
Patients undergoing early endovascular therapy, with a median time from stroke onset of 3.5 hours, demonstrated a substantially higher rate of neurological improvement after 3 days (80% vs. 37%) as well as a greater rate of independence at 90 days (71% vs. 40%). Patients receiving IV tPA and thrombectomy developed reperfusion of >90% of the at-risk territory within 24 hours (defined as the percentage reduction in the perfusion-lesion volume between initial and 24-hour imaging) in 89% of cases compared with 34%. Patients achieving this level of reperfusion were 4.5 times more likely to improve clinically in 90 days than those who did not. Likely due to this, patients had a substantially smaller infarct growth at 24 hours in the endovascular therapy group (10.9 vs. 35.3 mL). Interestingly, the long-term independence of patients undergoing thrombectomy in the EXTEND-IA trial was higher than those in ESCAPE trial. This could potentially relate to different selection criteria for CTP ...
Advances in Endovascular Treatment of Acute Ischemic Stroke
Internal medicine journal, 2014
Over the past decade, there have been rapid advancements in ischaemic stroke reperfusion treatments. Limitations of intra-venous thrombolysis include incomplete revascularisation in large vessel occlusion and a narrow therapeutic time window. These limitations are potentially addressed with the latest introduction of the stent retriever. However clear clinical benefit is yet to be shown in large clinical trials. The major studies in different types of endovascular treatments including intra-arterial thrombolysis, aspiration devices, mechanical clot retrievers and the new stent retrievers are discussed. The PROACT II and IMS II trials showed that intra-arterial thrombolysis had better functional outcome compared to intra-venous heparin or tPA alone; however, rates of complete recanalisation were not high. First generation mechanical thrombectomy devices such as the MERCI™ retriever and Penumbra aspiration device demonstrated safety and higher rates of recanalisation in the MERCI and ...
Frontiers in Neurology, 2020
Introduction: The practice of endovascular therapy has evolved dramatically over the last 10 years with randomized clinical trials investigating the benefit of thrombectomy in select patient populations based on time of presentation, imaging criteria, and procedural technique. We sought to understand the benefit of thrombectomy in patients treated within the context of a clinical trial at a single academic center. Methods: Patient-level data recorded in case forms and core-lab adjudicated data were analyzed from patients enrolled in RCTs investigating the benefit of endovascular thrombectomy over medical management (IMSIII, MR RESCUE, ESCAPE, SWIFT PRIME, and DAWN) between 2007 and 2017 at a single academic referral center. Results: A total of 134 patients (intervention group, n = 81; medical group, n = 53) were identified across five clinical trials (IMSIII, n = 46; MR RESCUE, n = 4; ESCAPE, n = 24; SWIFT PRIME, n = 14; DAWN, n = 46). There were no significant differences between the treatment arm and control arm in terms of age, gender, baseline NIHSS, ASPECTS, and site of occlusion. Rates of good outcome were superior in the intervention group with early neurological recovery (NIHSS of 0-1 or increase NIHSS of 8 points at 24 h) at a higher rate of 49% vs. 17% (p = <0.001) and higher rates of functional independence (90 day mRS 0-2 of 53% vs. 26%, p = 0.002). In multivariate logistic regression analysis, lower NIHSS and younger age were predictors of good outcome. There were comparable rates of good outcome irrespective of clinical trial, imaging selection criteria (CTP vs. MRI), early vs. late time window (0-6 h vs. 6-24 h) and procedural technique (Merci vs. Solitaire/Trevo device). There were no differences in rates of sICH, PH-2 or mortality in the intervention group vs. medical group. Conclusions: At a large academic center, the benefit of endovascular therapy over medical therapy is observed irrespective of clinical trial design, patient selection or procedural technique.
Expert Review of Cardiovascular Therapy, 2011
Stroke is the third leading cause of death and a leading cause of severe long-term disability worldwide. It costs the world's economy billions of dollars each year in physician services, hospital costs, lost wages and decreased productivity. Rapid advances in medical technology have resulted in an explosion of treatment strategies in the management of acute ischemic stroke. Each clinical scenario presents unique challenges related to risks and benefits of therapy. In this article, we review the evolution of endovascular therapy in acute ischemic stroke, discuss the latest advances, challenges and controversies in the field and speculate on the future of this therapy.
Endovascular Stroke Management: Key Elements of Success
Cerebrovascular diseases (Basel, Switzerland), 2016
In the last 12 months, treatment of acute ischaemic stroke secondary to large vessel occlusion has undergone a paradigm shift. The success of endovascular surgery, and in particular, the use of stent-retrievers, is remarkable. Beyond percentages and p values, the endovascular trials demonstrated, in their similarities and their differences, the critical elements of successful intervention in acute ischaemic stroke. Patient selection based on non-invasive neuroimaging has emerged as a critical step in acute ischaemic stroke management. The more sophisticated imaging-based selection, those assessing collateral blood flow or ischaemic penumbra appear to be associated with better outcomes and possibly fewer complications. The importance of achieving effective, quality reperfusion is also demonstrated, in a remarkably linear fashion, across the 5 published trials. This may emerge as the single most important determinant of functional outcomes. While reperfusion may succeed time as the pr...