Endovascular Therapies for Stroke Challenge the Adage ‘Time is Brain’
Following a landmark year for endovascular therapy, David Thaler, MD, PhD, of Tufts Medical Center, in Boston, Mass., gave a keynote speech in the Main Arena on Monday that highlighted recent strides in acute stroke intervention.
Referring to the commonly held adage “Time is Brain,” Thaler cited the National Institute of Neurological Diseases and Stroke (NINDS) tissue plasminogen activator (tPA) trial, which showed 20 years ago that patients could benefit when treated within 3 hours of symptom onset. Patients presenting beyond that window may represent an opportunity for endovascular therapy, he said.
Applying a ‘plumbing approach’
Endovascular techniques themselves have evolved, Thaler said, from past breakthroughs such as intra-arterial fibrinolysis and coil retrievers to the current generation of stent retrievers that actually remove the thrombus causing the stroke. Intra-arterial mechanical thrombectomy, also known as the “plumbing approach,” has emerged as a strong option for stroke patients, he noted.
Thaler reviewed results of MR CLEAN, EXTEND IA, ESCAPE, REVASCAT, and SWIFT PRIME, all of which showed an advantage for endovascular therapy (variously, mechanical thrombectomy and/or intraarterial thrombolysis) over IV thrombolysis. What was exciting were the “spectacularly similar results” among the trials, Thaler said, particularly the “improved neurological outcomes [that were] related to earlier treatment.” With endovascular therapy, treating patients in “less than 6 hours … is clearly effective based on the current data,” he said.
Teams are needed
Thaler noted that several questions about endovascular stroke therapy remain to be answered. Among them are how to treat tandem lesions, whether to opt for general anesthetic or conscious sedation during mechanical thrombectomy, and whether it is worth intervening in the care of patients up to 12 hours after a stroke if the penumbra can still be detected through imaging.
Importantly, the “systems of care are now going to have to be reorganized” with a nod to future regional and local changes to health care delivery, he stressed. This can be achieved through severity-adjusted triage of patients by EMS; the creation of Mobile Stroke Units; telemedicine-assisted ‘drip and ship’ of patients; and the training of a new generation of vascular neurologists capable both of administering tPA and performing intra-arterial thrombectomy in order to be in line with new protocols.
A digital discussion, moderated by Sahil A. Parikh, MD, of University Hospitals Case Medical Center, in Cleveland, Ohio, showed that clinicians are ready to embrace the new multidisciplinary approach to stroke.
“Stroke treatment is a matter of systemic approach,” wrote Ivo Petrov, MD, PhD, of City Clinic Sofia, in Bulgaria, adding that experienced interventional cardiologists can be crucial to a stroke team. In addition, Christine Roffe, MD, of Royal Stoke University Hospital, in the United Kingdom, commented: “Endovascular therapies will change the face of stroke medicine.”
- Thaler reports receiving consultant fees from St. Jude Medical and serving on the steering committee of the RESPECT trial.