Stroke: new horizons in treatment

Abstract

Intra-arterial therapy (IAT) has been used for three decades to promote recanalisation after stroke. Whereas results of the Prolyse in Acute Cerebral Thromboembolism-II trial (PROACT-II) 1 Furlan A Higashida R Wechsler L et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999; 282: 2003-2011 Crossref PubMed Scopus (2720) Google Scholar showed significant improvement in clinical outcome with intra-arterial fibrinolysis, the stroke specialty received some disturbing news in 2013. Results of the Interventional Management of Stroke-III (IMS-III), 2 Broderick JP Palesch YY Demchuk AM et al. for the Interventional Management of Stroke (IMS) III InvestigatorsEndovascular therapy after intravenous t-PA vs t-PA alone for stroke. N Engl J Med. 2013; 368: 893-903 Crossref PubMed Scopus (1421) Google Scholar SYNTHESIS, 3 Ciccone A Valvassori L Nichelatti M et al. for the SYNTHESIS Expansion InvestigatorsEndovascular treatment for acute ischemic stroke. N Engl J Med. 2013; 368: 904-913 Crossref PubMed Scopus (357) Google Scholar and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) 4 Kidwell CS Jahan R Gornbein J et al. for the MR RESCUE InvestigatorsA trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013; 368: 914-923 Crossref PubMed Scopus (1091) Google Scholar studies failed to show an increased benefit for IAT compared with intravenous alteplase (t-PA) or as an adjunctive approach to intravenous alteplase. All three studies were randomised controlled trials: IMS-III assessed the adjunctive benefit of IAT with intravenous alteplase, SYNTHESIS tested IAT efficacy against intravenous alteplase, and MR RESCUE tried to identify patients most likely to benefit from IAT on the basis of a favourable imaging profile showing a penumbral pattern. IAT advocates have pointed out that newer devices than those used in these studies might achieve more rapid and complete recanalisation and better outcomes. A post-hoc analysis from IMS-III showed that patients treated within 4 h from symptom onset have potential to benefit most from IAT. Furthermore, new data showing improved reperfusion rates and times with the introduction of stent retrievers could result in improved clinical outcomes. 5 Saver JL Jahan R Levy EI et al. for the SWIFT TrialistsSolitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012; 380: 1241-1249 Summary Full Text Full Text PDF PubMed Scopus (1051) Google Scholar , 6 Nogueira RG Lutsep HL Gupta R et al. for the TREVO2 trialistsTrevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012; 380: 1231-1240 Summary Full Text Full Text PDF PubMed Scopus (889) Google Scholar