In this part 2 of EM Cases Journal Jam podcast on Thrombolysis and Endovascular Therapy for Stroke Justin Morgenstern, Rory Spiegel and Anton Helman do a deep dive into the world’s literature on endovascular therapy for stroke. While the evidence for endovascular therapy is stronger than that for IV systemic thrombolysis for stroke outcomes at 90 days, a closer look at the literature reveals that a very small minority of patients are eligible for endovascular therapy and we still don’t know which patients benefit most from endovascular therapy…

Podcast produced by Anton Helman, Justin Morgenstern and Rory Spiegel; sound design and editing by Anton Helman; EBM bomb by Anton Nikoline.

Written Summary and blog post by Anton Helman July, 2016

Cite this podcast as: Morgenstern, J, Spiegel, R, Helman, A. Part 2 Endovascular Therapy for Stroke. Emergency Medicine Cases. July, 2016. https://emergencymedicinecases.com/endovascular-therapy-stroke/. Accessed [date].

Endovascular Therapy for Stroke Trials

Adapted from R.E.B.E.L. EM

IMS-IIIBroderick JP2013No benefit
MR RESCUEKidwell CS2013No benefit
SYNTHESISCiccone A2013No benefit
MR CLEANFransen PS201413.5%  disability benefit
ESCAPEGoyal M201524%  disability benefit
EXTEND IACampbell BC    2015     31%  disability benefit
SWIFT PRIME    Saver JL201526%  disability benefit
REVASCATJovin TG201516%  disability benefit
THRACEBracard S201611%  disability benefit
THERAPYMocco J20168%  disability benefit

 

A very small percentage of patients with acute stroke (about 1%) will be eligible for endovascular therapy. Most of the trials listed above enrolled patients with anterior circulation large vessel severe strokes that have demonstrable salvageable brain tissue on imaging.

 

Issues with these endovascular therapy for stroke trials

  • Open label (not blinded)
  • Many were stopped early
  • Inclusion criteria were heterogeneous between trials – different imaging requirements, differents timeframes, most people got tPa (but some didn’t), different interventions in addition to thrombectomy
  • Indication creep (see this post by Kevin Klauer for explanation)

 

Food for thought on endovascular therapy for stroke

The bigger question is whether the small benefits of endovascular therapy to a very small number of patients is worth the larger societal costs of interventional radiologists on call, equipment, administration etc. for “code stroke” to be called at any time of day.

 

Drs. Helman, Morgenstern and Spiegel have no conflicts of interest to declare

 

References

Broderick JP et al. Endovascular Therapy After Intravenous t-PA Versus t-PA Alone for Stroke. NEJM 2013; 368(10): 893-903.

Kidwell CS et al. A Trial of Imaging Selection and Endovascular Treatment for Ischemic Stroke. NEJM 2013; 368(10): 914-23.

Ciccone A et al. Endovascular Treatment for Acute Ischemic Stroke. NEJM 2013; 368(10): 904-13.

Fransen PS et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. NEJM 2015; 372(1): 11-20.

Goyal M et al. Randomized Assessment of rapid Endovascular Treatment of Ischemic Stroke. NEJM 2015; 372(11): 1019-30.

Campbell BC et al. Endovascular Therapy for ISchemic Stroke with Perfusion-Imaging Selection. NEJM 2015; 372(11): 1009-18.

Saver JL et al. Stent-Retriever Thrombectomy after Intravenous t-PA vs t-PA Alone in Stroke. NEJM 2015; 372(24): 2285-95.

Jovin TG et al. Thrombectomy Within 8 Hours After Symptom Onset in Ischemic Stroke. NEJM 2015; 372(24): 2296-306.

Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016;15(11):1138-47.

Mocco J et al. Aspiration Thrombectomy After Intravenous Alteplase Versus Intravenous Alteplase Alone. Stroke. 2016;47(9):2331-8.

 

Other FOAMed Resources on Endovascular Therapy for Stroke

First10EM Interventional Therapy for Acute Ischemic Stroke: The Evidence

EMDocs Endovascular Stroke Therapy: Is this the new standard?

The SGEM reviews the 2015 JAMA Meta-analysis on endovascular stroke treatement

EMLit of Note Christmas Comes Early for Endovascular Therapy in Stroke