Endovascular interventions for acute stroke: past practice and current research

Abstract

The way clinical care and research are currently conceived is entangled in multiple problems. While the problems are universal, nowhere were they more painfully experienced than in the acute care of patients with severe stroke. While we are celebrating that we now possess evidence that patients can benefit from endovascular interventions, we should not miss the opportunity to review the difficult path that led to this point and reflect on how it could be improved. A narrative review of the past and current status of care and research in endovascular treatment of acute stroke may serve to expose the problems and potential solutions. For more than 25 years, rescue endovascular interventions were offered to selected patients using a vast array of drugs and devices not designed for that purpose with little success, at least in the early years.1 Occasionally, a Lazarus experience (spectacular recovery associated with recanalization) would fuel enough enthusiasm to go on for another long run of failures. We have always been aware that the occasional miracle could not justify a full-scale campaign for the massive resources required to staff centers with expert personnel, streamlined patient transportation, not to mention the generous budget needed for such high-technology care. Clinical research thus focused on intravenous (IV) therapy, a simpler approach which can be delivered locally.2 Following the positive National Institute of Neurological Disorders and Stroke (NINDS) study, subsequent research endeavors were largely devoted to neuroprotective agents promoted by the pharmaceutical industry. Meanwhile, increasingly effective endovascular tools became available, but regulatory agencies never required proof of clinical benefit (angiographic demonstration that vessels can be recanalized would typically suffice) to authorize the sale of ever more expensive devices. Intra-arterial (IA) therapy thus did not have the financial impetus to rigorously assess patient outcomes. Until recently, in the presence of large …