Abstract
Due to recent results from clinical intra-arterial treatment for acute ischemic stroke (IAT-AIS) trials such as the interventional management of stroke III, IAT-AIS and the merit of revascularization have been contested. Even though intra-arterial treatment (IAT) has been shown to improve revascularization rates, a corresponding increase in good outcomes has only recently been noted. Even though a significant percentage of patients achieve good revascularization in a timely manner, results do not translate into good clinical outcomes (GCOs). Based on a review of the literature, the authors suspect limited GCOs following timely and successful revascularization are due to poor patient selection that led to futile and possibly even harmful revascularization. The capillary index score (CIS) is a simple angiography-based scale that can potentially be used to improve patient selection to prevent revascularization being performed on patients who are unlikely to benefit from treatment. The CIS characterizes presence of capillary blush related to collateral flow as a marker of residual viable tissue, with absence of blush indicating the tissue is no longer viable due to ischemia. By only selecting patients with a favorable CIS for IAT, the rate of GCOs should consistently approach 80–90%. Current methods of patient selection are primarily dependent on time from ischemia. Time from cerebral ischemia to irreversible tissue damage seems to vary from patient to patient; so focusing on viable tissue based on the CIS rather than relying on an artificial time window seems to be a more appropriate approach to patient selection.
Highlights
The interventional management of stroke (IMS) III trial [1] showed non-superiority of intraarterial (IA) revascularization combined with intra venous (IV) tissue plasminogen activator treatment over IV tPA alone, and the systemic thrombolysis for acute ischemic stroke (SYNTHESIS) trial demonstrated similar lack of favorable clinical outcomes for IA versus IV tPA therapy [2]
By adapting the capillary index score (CIS) for patient selection and a more nuanced strategy for revascularization, we should consistently approach the 80–90% clinical improvement rate in the treated subgroup, as we saw in the Borgess Medical Center-acute ischemic stroke registry (BMC-AIS) registry and the subgroup analysis of IMS I, II
This percentage cannot be reached using IV treatment alone due to the lower revascularization rate associated with IV treatment and its inability to assess the collateral supply prior to treatment, which will invariably lead to a higher percentage of futile and harmful recanalization
Summary
The interventional management of stroke (IMS) III trial [1] showed non-superiority of intraarterial (IA) revascularization combined with intra venous (IV) tissue plasminogen activator (tPA) treatment over IV tPA alone, and the systemic thrombolysis for acute ischemic stroke (SYNTHESIS) trial demonstrated similar lack of favorable clinical outcomes for IA versus IV tPA therapy [2]. In order to enhance the benefit of intra-arterial treatment (IAT), we need first to redefine our revascularization strategy by minimizing the performance of futile and harmful revascularization To achieve this goal, we propose the following strategy: select patients correctly with f CIS and obtain as complete and timely revascularization as safely possible, solely to the viable tissue, i.e., the areas with persistent capillary blush. By adapting the CIS for patient selection and a more nuanced strategy for revascularization, we should consistently approach the 80–90% clinical improvement rate in the treated subgroup, as we saw in the BMC-AIS registry and the subgroup analysis of IMS I, II This percentage cannot be reached using IV treatment alone due to the lower revascularization rate associated with IV treatment and its inability to assess the collateral supply prior to treatment, which will invariably lead to a higher percentage of futile and harmful recanalization. We propose that approximately half of all AIS patients do
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