R.E.B.E.L.EM - March 15, 2018 - By Salim Rezaie
Clinical Take Home Point:
- Systemic IV thrombolysis can have limited responsiveness (13 – 50%) to large thrombi in the central circulation, a narrow time window for administration (4.5hrs), and increases the risk of cerebral/systematic hemorrhage
- The initial 3 trials showing no difference in 90d mRs scores were most likely due to:
- Proximal occlusion not radiologically proven with intracranial occlusions (i.e. CTA, MRA)
- The use of first-generation Merci devices as opposed to retrievable stents
- It is also important to note that in many of the earlier trials there were more new strokes and vessel dissections compared to systemic therapy
- In the studies reviewed, recruitment averaged about 1 patient per month, meaning this was a very specific and particular patient that was recruited
- As more and more trials have been performed, the efficiency, the type of imaging, and technology have all also improved, minimizing complications and improving efficacy of endovascular therapy
- Endovascular therapy for ischemic stroke is suitable for patients with ischemic stroke within 24hrs of symptom onset, with:
- Proof of proximal intracranial vessel occlusion
- Imaging methods to exclude large infarct cores
- Efficient workflow to achieve fast recanalization and high reperfusion rates
- Workflow: Ischemic Stroke Symptoms ≤24hrs -> CT/CTA -> If CTA positive for large anterior (ICA/MCA) stroke -> CT or MR Perfusion Scan to determine eligibility for Endovascular Therapy
- Later trials included patients with “wake up” strokes, which have not previously been included in systemic t-PA trials
- One final note: It is important to realize that many trials were stopped early, and because of this the magnitude of benefit for endovascular therapy may be over inflated in many of these trials