By Matthew E. Fink, MD
Professor and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a consultant for Procter & Gamble.
Major announcements at the International Stroke Conference 2015 in Nashville, Tennessee, included reports on three trials that compared endovascular clot retrieval for acute ischemic stroke, compared to medical treatment with intravenous thrombolytics alone. In a stunning reversal of the negative studies that were reported just 1 year ago, three trials all reported positive results. In the EXTEND–IA trial, more brain was reperfused 24 hours after endovascular thrombectomy in patients who also received intravenous alteplase, than those getting IV thrombolytic treatment alone. In the SOLITAIRE-F stent-retriever device study, where the intra-arterial device was deployed within 4.5 hours of stroke onset, functional independence at 90 days, based on the modified Rankin score, was better than treatment with IV thrombolytics alone. The third trial, ESCAPE, was a similar comparison between usual medical care, usually intravenous alteplase, compared to available embolectomy devices within 12 hours of onset, and even with such a delay, there was a significant downward shift in the modified Rankin score with the intervention group showing better functional outcome at 90 days, 53% vs 29% in the modified Rankin score 0-2. The ESCAPE trial also showed a reduction in 90-day mortality, in favor of the interventional treatment, 10.4% vs 19%.
Why did these studies show improved outcome when similar trials in the past have failed? These new devices were improved technologically, the interval from onset of symptoms to puncture and endovascular treatment was generally shorter, and patient selection was excellent with the use of CT angiography to identify large vessel occlusions in a rapid fashion.
The studies are being simultaneously published in the New England Journal of Medicine, and more details will be available for all of us to review. These recent reports will usher in a new era in acute ischemic stroke therapy.