On behalf of the SP Stroke management group.
In 2015 acute stroke therapy has taken an important step forward with a series of trials which have shown a better functional outcome of patients with stroke from large vessel occlusion undergoing endovascular thrombectomy than receiving just intravenous thrombolysis. Although these positive results are strengthened by a careful meta-analysis of altogether 8 trials involving a total of 2423 patients(1) these data have also limitations such as the premature stopping of 5 of these trials either for futility or following a positive interim analysis. Furthermore patient selection criteria, time window and employed procedures were quite variable between trials and several questions for thrombectomy in clinical practice are still unresolved (2). In this regard a consensus statement on “Mechanical thrombectomy in acute ischemic stroke” spearheaded by the ESO-Karolinska Stroke Update conference and supported by several societies should be helpful (3). An important next step will be to organize access to thrombectomy with appropriate quality for all patients who are likely to benefit on the basis of the current recommendations. In parallel we need to collect further data regarding optimal patient selection and interventional strategies. Thus despite all excitement there is still a lot of work ahead and we are all asked to contribute.
(1) Badhiwala JH, Nassiri F, Alhazzani W, Selim MH, Farrokhyar F, Spears J, et al. Endovascular thrombectomy for acute ischemic stroke: A meta-analysis.
JAMA. 2015;314: 1832-1843
(2) Wardlaw JM, Dennis MS.
Thrombectomy for acute ischemic stroke.
(3) Wahlgren N, Moreira T, Michel P, Steiner T, Jansen O, Cognard C, et al.
Mechanical thrombectomy in acute ischemic stroke: Consensus statement by eso-karolinska stroke update 2014/2015, supported by ESO, ESMINT, ESNR and EAN.
Int J Stroke. 2016; 11:134-147
Key points (from Ref. 3)
· Mechanical thrombectomy, in addition to intravenous thrombolysis within 4.5 h when eligible, is recommended to treat acute stroke patients with large artery occlusion in the anterior circulation up to 6h after symptom onset.
· Mechanical thrombectomy should not prevent the initiation of intravenous thrombolysis where this is indicated, and intravenous thrombolysis should not delay mechanical thrombectomy.
· For mechanical thrombectomy, stent retrievers approved by local health authorities should primarily be considered.
· If intravenous thrombolysis is contraindicated (e.g. Warfarin-treated with therapeutic INR) mechanical thrombectomy is recommended as first-line treatment in large vessel occlusions