Stroke Treatment: Current News and Developments

Abstract

Several studies regarding the treatment of both acute ischemic and hemorrhagic stroke, and the secondary prevention have been completed and presented in the first few months of this year. The main results of these controversial studies are discussed in this article. Neurothrombectomy is the new standard in the treatment of acute ischemic stroke. During the 9th World Stroke Congress in Istanbul, the treatment of acute stroke entirely changed with presentation of the positive results of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MrClean) study on October 28th, 2014, regarding the effectiveness of thrombectomy. Following the announcement of these positive results, data collection in other thrombectomy studies with similar designs was aborted and the results were subjected to analysis; all neurologists became enthusiastic about the positive results for which they had been waiting for (1). However, this enthusiasm has waned after a more careful evaluation of the situation, because many countries, including Turkey, do not have the economic capacity to broadly and ethically implement this treatment. Therefore, it is believed that it is time to reorganize and implement the national acute stroke treatment system (2). The use of previous methods is no longer possible. The results were striking and they cannot be ignored. The highly effective reperfusion evaluated in Multiple Endovascular Stroke collaboration pooled data from five trials and found that the number needed to treat with endovascular thrombectomy to reduce disability by at least one level on the modified Rankin scale for one patient was 2.6 (3). Of course, this rate is a very rare; a fairly low rate in medicine. However, thrombectomy should be performed within 6-12 hours after stroke, so patients must be referred to eligible treatment centers within this short period of time known as the “therapeutic window.” In this case, regional regulations and national dissemination seems to be obligatory. Stroke can be observed everywhere, not only in metropoles, and every patient with severe stroke can only be treated in this way. Turkey was one of the last countries in Europe to initiate intravenous thrombolytic treatment. To avoid a similar situation in thrombectomy, and for the benefit of our patients and people, this scientific data must be implemented in Turkey with a collaborative and multidisciplinary approach. It is clear that Turkish Neurological Society should undertake the most critical role in this context. Low-dose intravenous thrombolytic treatment is not more effective in acute ischemic stroke. In the Enhanced Control of Hypertension and Thrombolysis Stroke Study, low-dose (0.6 mg/kg) and standard dose (0.9 mg/ kg) intravenous tissue plasminogen activator (tPA) were compared in 3.310 patients within 4.5 hours of the onset of stroke (4). The primary outcome was death or disability at 90 days, and was found similar in both groups (53.2% with low-dose tPA and 51.1% with standard dose). However, although mortality rates were less with low-dose, disability rates tended to be higher. This study suggests that 19 patients would not die if 1.000 patients were given low-dose tPA instead of a standard dose, but an extra 40 patients would be disabled. Also, major symptomatic intracerebral hemorrhage was less with low-dose tPA (1% vs. 2.1%). Although