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Correspondence Endovascular treatment of acute ischemic stroke: Not yet a panacea for all troubles Sir, We read with interest the article “Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center” by Huded et al.[1] The authors present impressive data on outcomes following endovascular treatment in acute stroke. As rightly indicated by the authors, delay in reporting to a healthcare facility is a major hurdle in management of acute stroke in the Indian setting. However, we are unsure whether endovascular therapy is the right solution to this problem. One of the important lessons learned from IMS‑3 was that functional benefit was noted in those who received IV thrombolysis within the recommended window period regardless of whether they received endovascular therapy.[2] Hence, the emphasis is still on providing IV thrombolysis to eligible patients. Notably, patients in IMS‑3 intervention arm who received no IV therapy due to various exclusion reasons did not show any functional benefit at 3 months despite good recanalization rates. This leads us to speculate whether the patients who showed functional improvement at 3 months in the present study were those who received IV thrombolysis within the window period as well? Moreover, the etiology of stroke is not clear in this study. Cardioembolic strokes are likely to recanalize earlier and have better functional outcomes eventually. It would also be prudent to know the proportion of patients who had excellent recovery at 24 hours (NIHSS improvement >9 points or 0) and whether any of the patients required decompressive craniotomy following a complete recanalization. The younger mean age of patients in the present study might also mean that risk factors other than the traditional atherosclerotic risk factors may be responsible for stroke in these patients. Moreover, as pointed out by the authors, younger patients tend to have better recovery after stroke.[3] Time to reperfusion is a major determinant of outcomes and it would be interesting to know whether the time to recanalization influenced outcomes and hemorrhage rates.[4] In spite of the excellent outcome results seen in this study, we remain skeptical about the current status of endovascular therapy in an acute stroke setting and believe that it is still premature to consider primary endovascular therapy as efficacious in acute stroke. Until larger studies show a stronger correlation 468
between recanalization rates and functional outcome, IV thrombolysis remains the gold standard for management of acute stroke.
R. Rajan, D. Khurana Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India E‑mail: [email protected]
References 1. 2.
3. 4.
Huded V, Nair RR, deSouza R, Vyas DD. Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center. Neurol India 2014;62:276‑9 Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Interventional Management of Stroke (IMS) III Investigators. Interventional management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t‑PA versus t‑PA alone for stroke. N Eng J Med 2013;368:893‑903. Singer OC, Haring HP, Trenkler J, Nolte CH, Bohner G, Reich A, et al. Age dependency of successful recanalization in anterior circulation stroke: The ENDOSTROKE study. Cerebrovasc Dis 2013;36:437‑45. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: A meta‑analysis. Stroke 2007;38:967‑73. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.141298
Received: 29-07-2014 Review completed: 07-09-2014 Accepted: 07-09-2014
Authors reply Sir, In the Interventional Management of Stroke III (IMS3)[1] study, the participants were randomly assigned, either to the intravenous arm or to the endovascular treatment arm. CT angiogram was not consistently used as a parameter for evaluating strokes due to large vessel occlusions. Some of the patients randomized to the endovascular group showed no evidence of any vascular lesion. It is difficult to comment as to how many patients who received intravenous thrombolysis (IVT) and showed good improvement actually had a transient ischemic attack (TIA) or were functional. The initial criterion used in the study was a National Institutes of Health Stroke Scale (NIHSS) of greater than 10, suggestive of a large vessel occlusion. A high NIHSS score may also be seen in a left middle cerebral artery (MCA) infarct in spite of the aetiology Neurology India | Jul-Aug 2014 | Vol 62 | Issue 4
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Correspondence Endovascular treatment of acute ischemic stroke: Not yet a panacea for all troubles Sir, We read with interest the article “Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center” by Huded et al.[1] The authors present impressive data on outcomes following endovascular treatment in acute stroke. As rightly indicated by the authors, delay in reporting to a healthcare facility is a major hurdle in management of acute stroke in the Indian setting. However, we are unsure whether endovascular therapy is the right solution to this problem. One of the important lessons learned from IMS‑3 was that functional benefit was noted in those who received IV thrombolysis within the recommended window period regardless of whether they received endovascular therapy.[2] Hence, the emphasis is still on providing IV thrombolysis to eligible patients. Notably, patients in IMS‑3 intervention arm who received no IV therapy due to various exclusion reasons did not show any functional benefit at 3 months despite good recanalization rates. This leads us to speculate whether the patients who showed functional improvement at 3 months in the present study were those who received IV thrombolysis within the window period as well? Moreover, the etiology of stroke is not clear in this study. Cardioembolic strokes are likely to recanalize earlier and have better functional outcomes eventually. It would also be prudent to know the proportion of patients who had excellent recovery at 24 hours (NIHSS improvement >9 points or 0) and whether any of the patients required decompressive craniotomy following a complete recanalization. The younger mean age of patients in the present study might also mean that risk factors other than the traditional atherosclerotic risk factors may be responsible for stroke in these patients. Moreover, as pointed out by the authors, younger patients tend to have better recovery after stroke.[3] Time to reperfusion is a major determinant of outcomes and it would be interesting to know whether the time to recanalization influenced outcomes and hemorrhage rates.[4] In spite of the excellent outcome results seen in this study, we remain skeptical about the current status of endovascular therapy in an acute stroke setting and believe that it is still premature to consider primary endovascular therapy as efficacious in acute stroke. Until larger studies show a stronger correlation 468
between recanalization rates and functional outcome, IV thrombolysis remains the gold standard for management of acute stroke.
R. Rajan, D. Khurana Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India E‑mail: [email protected]
References 1. 2.
3. 4.
Huded V, Nair RR, deSouza R, Vyas DD. Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center. Neurol India 2014;62:276‑9 Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Interventional Management of Stroke (IMS) III Investigators. Interventional management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t‑PA versus t‑PA alone for stroke. N Eng J Med 2013;368:893‑903. Singer OC, Haring HP, Trenkler J, Nolte CH, Bohner G, Reich A, et al. Age dependency of successful recanalization in anterior circulation stroke: The ENDOSTROKE study. Cerebrovasc Dis 2013;36:437‑45. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: A meta‑analysis. Stroke 2007;38:967‑73. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.141298
Received: 29-07-2014 Review completed: 07-09-2014 Accepted: 07-09-2014
Authors reply Sir, In the Interventional Management of Stroke III (IMS3)[1] study, the participants were randomly assigned, either to the intravenous arm or to the endovascular treatment arm. CT angiogram was not consistently used as a parameter for evaluating strokes due to large vessel occlusions. Some of the patients randomized to the endovascular group showed no evidence of any vascular lesion. It is difficult to comment as to how many patients who received intravenous thrombolysis (IVT) and showed good improvement actually had a transient ischemic attack (TIA) or were functional. The initial criterion used in the study was a National Institutes of Health Stroke Scale (NIHSS) of greater than 10, suggestive of a large vessel occlusion. A high NIHSS score may also be seen in a left middle cerebral artery (MCA) infarct in spite of the aetiology Neurology India | Jul-Aug 2014 | Vol 62 | Issue 4
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
