Editorial
Endovascular treatment in acute ischemic stroke: Where it stands? J. M. K. Murthy Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad, Andhra Pradesh, India Address for correspondence: Dr. J. M. K. Murthy, Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad ‑ 500 034, Andhra Pradesh, India. E‑mail: [email protected] Received : 03‑02‑2014 Review completed : 03‑02‑2014 Accepted : 03‑02‑2014
Early recanalization within 4.5 h is the proven treatment in acute ischemic stroke. Data from randomized clinical trials have established the clinical efficacy of intravenous tissue plasminogen activator (IV tPA) for carefully selected patients with acute ischemic stroke when administered within 4.5 h of onset.[1‑4] However, the outcome is poor for patients with large artery‑occlusion even when administrated within the 4.5‑h window.[1,5,6] Rescue endovascular treatment may be an alternate approach to recanalization in patients with large‑artery occlusion who have not responded to IV tPA. This approach may minimize or obviate the use of chemical thrombolytics, thereby decreasing the risk of intracerebral hemorrhage. The recent endovascular treatment trials in acute ischemic stroke: Interventional Management of Stroke (IMS) III,[7] Magnetic Resonance and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE),[8] and SYNTHESIS EXPANSION[9] have not shown a large magnitude benefit of endovascular treatment over IV tPA alone in IV tPA‑eligible patients, even in patients with persistent Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.136892
Neurology India | May-Jun 2014 | Vol 62 | Issue 3
large‑artery occlusion. These trials have also not demonstrated endovascular treatment superior to IV tPA in ineligible patients because they exceeded the window period (>4.5 h). Rates of intracerebral hemorrhages were similar between IV tPA and endovascular treatment.[7,9] Various mechanical clot retrieval devices used in various trials include MERCI retriever (Concentric Medical), Penumbra System (Penumbra), Solitaire (Covidien), and Trevo (Concentric/Stryker) stent retrievers. In recent literature review, MERCI retriever has been shown to be safe, with recanalization rate of 63.6%, 90‑day mRS ≤2 of 32.0%, and 90‑day mortality of 35.2%.[10] The Penumbra Pivotal Stroke trial showed that Penumbra device is safe, with recanalization rate of 82%, 90‑day mRS ≤R2 of 25%, and 90‑day mortality of 32.8%.[11] Stent retrievers Solitaire (Covidien) and Trevo (Concentric/Stryker) have been introduced recently. No significant differences were found in the rate of recanalization rates between the two devices.[12] A systemic review of the use of Solitaire stent retriever in patients with ischemic stroke showed the safety of the device with a recanalization rate of 89.7% and a favorable outcome of mRS
Endovascular treatment in acute ischemic stroke: Where it stands? J. M. K. Murthy Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad, Andhra Pradesh, India Address for correspondence: Dr. J. M. K. Murthy, Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad ‑ 500 034, Andhra Pradesh, India. E‑mail: [email protected] Received : 03‑02‑2014 Review completed : 03‑02‑2014 Accepted : 03‑02‑2014
Early recanalization within 4.5 h is the proven treatment in acute ischemic stroke. Data from randomized clinical trials have established the clinical efficacy of intravenous tissue plasminogen activator (IV tPA) for carefully selected patients with acute ischemic stroke when administered within 4.5 h of onset.[1‑4] However, the outcome is poor for patients with large artery‑occlusion even when administrated within the 4.5‑h window.[1,5,6] Rescue endovascular treatment may be an alternate approach to recanalization in patients with large‑artery occlusion who have not responded to IV tPA. This approach may minimize or obviate the use of chemical thrombolytics, thereby decreasing the risk of intracerebral hemorrhage. The recent endovascular treatment trials in acute ischemic stroke: Interventional Management of Stroke (IMS) III,[7] Magnetic Resonance and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE),[8] and SYNTHESIS EXPANSION[9] have not shown a large magnitude benefit of endovascular treatment over IV tPA alone in IV tPA‑eligible patients, even in patients with persistent Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.136892
Neurology India | May-Jun 2014 | Vol 62 | Issue 3
large‑artery occlusion. These trials have also not demonstrated endovascular treatment superior to IV tPA in ineligible patients because they exceeded the window period (>4.5 h). Rates of intracerebral hemorrhages were similar between IV tPA and endovascular treatment.[7,9] Various mechanical clot retrieval devices used in various trials include MERCI retriever (Concentric Medical), Penumbra System (Penumbra), Solitaire (Covidien), and Trevo (Concentric/Stryker) stent retrievers. In recent literature review, MERCI retriever has been shown to be safe, with recanalization rate of 63.6%, 90‑day mRS ≤2 of 32.0%, and 90‑day mortality of 35.2%.[10] The Penumbra Pivotal Stroke trial showed that Penumbra device is safe, with recanalization rate of 82%, 90‑day mRS ≤R2 of 25%, and 90‑day mortality of 32.8%.[11] Stent retrievers Solitaire (Covidien) and Trevo (Concentric/Stryker) have been introduced recently. No significant differences were found in the rate of recanalization rates between the two devices.[12] A systemic review of the use of Solitaire stent retriever in patients with ischemic stroke showed the safety of the device with a recanalization rate of 89.7% and a favorable outcome of mRS
