The Quest to Prove Endovascular Stroke Therapy: Searching for the “Sweet Spot” in Patient Selection

Abstract

Endovascular interventions targeted at improving outcomes in patients with acute ischemic stroke have been studied for more than 2 decades. During this period, intravenous (IV) recombinant tissue plasminogen activator (tPA) was established as an effective treatment for stroke, providing the impetus to build organized stroke systems of care and revolutionizing the treatment of stroke worldwide. Endovascular approaches to achieve revascularization in cerebral arteries have been proposed to have a number of advantages over IV tPA, including greater efficacy at reopening occluded vessels and fewer systemic bleeding risks. Although intra-arterial administration of thrombolytic agents has been shown to improve outcomes compared with placebo, proof of superior outcomes relative to IV tPA remains elusive.1 In this issue of Mayo Clinic Proceedings, Singh et al2 present a detailed meta-analysis of studies comparing endovascular therapy with IV tPA. Such an analysis is challenging, ie, pooling of heterogeneous studies with different inclusion criteria and different treatment approaches has the potential to create more confusion than clarity. The study design used by Singh et al included measures to work around these problems.