Endovascular stroke therapy a new era - Wiley Online Library

4 downloads 0 Views 60KB Size Report
Endovascular treatment of acute ischemic stroke is a therapy with a visible effect. With reperfusion, patients can get better on the angiogram suite table. We know ...
Leading opinion Endovascular stroke therapy – a new era Michael D. Hill, Mayank Goyal, and Andrew M. Demchuk Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada

Endovascular treatment of acute ischemic stroke is a therapy with a visible effect. With reperfusion, patients can get better on the angiogram suite table. We know that in the right patient, this therapy can be highly effective because our patients are hemiplegic, and then they are not. They come in on a stretcher and they walk out of hospital back into their lives. Yet we have not been able to convincingly and consistently prove this effect in randomized trials. Why? Intra-arterial thrombolysis for ischemic stroke was reported in 1958 (1), but came of age with the PROACT-2 trial in 1999 (2). It was waylaid by manufacturing and business events that prevented progression to a second trial and licensing of pro-urokinase. The use of intra-arterial tissue plasminogen activator (tPA) was never an on-label treatment, but was well accepted in the stroke community, particularly as part of the Interventional Management of Stroke (IMS) trials (3–5). The US regulatory and subsequent remuneration decisions to accept and pay for the MERCI retriever for ischemic stroke treatment had global influence (6). This decision simultaneously impeded randomized clinical trials enrollment and launched a wave of innovation in intracranial catheter development. Without this decision, more randomized clinical trials comparing endovascular vs. control would have been completed faster, but we may not have had such a rapid cycle of innovation of new devices culminating in the revolutionary stentrievers. The evolution of imaging has played a prominent role in ischemic stroke management. With fast computed tomography (CT) helical acquisition, it is possible to rapidly obtain vascular imaging in stroke syndrome presentations. In Calgary, we have Correspondence: Michael D. Hill – Departments of Clinical Neurosciences, Medicine, Radiology and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada Mayank Goyal – Departments of Radiology, Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada Andrew M. Demchuk – Departments of Clinical Neurosciences, Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada Conflict of interest: The authors are the Co-PIs of the ESCAPE trial. Funding: ESCAPE was funded by a consortium including grants from Covidien, Heart & Stroke Foundation Alberta, Alberta Innovates Health Solutions, Department of Clinical Neurosciences, Department of Radiology, University of Calgary, Hotchkiss Brain Institute, Calgary Stroke Program, Alberta Health Services. Statement of Authorship: M. D. H. wrote the first draft. All authors contributed to the final manuscript. DOI: 10.1111/ijs.12456

278

Vol 10, April 2015, 278–279

found that this is incredibly impactful in both major and minor stroke and hemorrhage, such that we do this routinely now on all stroke syndrome patients. These data are very rapidly obtainable (in minutes), similar across platforms and CT manufacturers, and reproducibly interpreted. We have further modified the technique to obtain a multiphase CT angiography (CTA), providing timeresolved images that assess collateral filling. While there have been improvements in CT perfusion, it remains vulnerable to patient motion and is less comparable and standardized across platforms. Magnetic resonance (MR) imaging provides greater spatial resolution and physiological information, but simply takes too much time; in acute stroke, the role of MR will be clinical situations where time is not limited. A meta-analysis including 395 patients showed a beneficial effect of intra-arterial thrombolysis, driven by PROACT-2 and MELT studies (7). Multiple cohort studies showed that recanalization with endovascular thrombectomy was associated with better outcome, even in later (