Thursday, April 11, 2019

Endovascular Therapy for AIS

R.E.B.E.L.EM - April 11, 2019 - By Michael Pallaci
"Clinical Bottom Line
  • 8 RCTs have demonstrated the benefit of EST (NNT: 2-12) for a highly selected group of patients: large anterior strokes with a demonstrable clot in a large vessel (distal ICA, ACA, MCA) with a small ischemic core and large salvageable penumbra
  • There are issues with the data, but unlike IV tPA for stroke, the results for EST have been consistently replicated
    • EST benefits only about 1 of every 770 patients with acute ischemic stroke
  • The extended treatment windows resulting from the DAWN and DEFUSE-3 trials may bring that number down
  • Areas for future study:
    • Attempting to identify more patients who benefit
    • EST alone for patients in the window for IV tPA (unlikely in the current climate)
    • Confirming benefit out to 24 hours (i.e., replicating the DAWN trial)
Endovascular stroke therapy will be one of the most hotly debated topics for the next several years. Despite the flaws in the evidence, the reproducibility and wildly positive results of the studies provide some optimism that, for the tiny subset of patients who meet the inclusion criteria, significant benefit is possible. But the societal costs and potential for indication creep are major causes for concern, and will undoubtedly lead to battle lines being drawn and fiercely defended, just as has been the case for IV thrombolysis for stroke for the past two decades."