Lessons learnt from recent endovascular stroke trials: finding a way to move forward

Abstract

The advent of stentrievers provided momentum for endovascular stroke therapy. Hopes were dampened after three randomized trials showed no clear benefit of endovascular therapy. This review discusses the results of these trials results and shortcomings. A detailed discussion will follow on the design, conduct and analysis of current and future endovascular stroke trials. Steps to improve the workflow of acute stroke cases from the time they enter the emergency department until endovascular reperfusion is achieved can significantly shorten the time from onset to successful reperfusion. These factors in addition to using novel approaches to analyze data and minimize delays caused by the consent process are perceived to be sufficient to demonstrate the efficacy of endovascular stroke therapy.

Keywords::

• acute cerebral infarction
• cerebrovascular disease
• endovascular therapy
• intravenous alteplase
• stent retrievers
• thrombolysis

Financial & competing interests disclosure

B Menon is supported by a Heart and Stroke Foundation of Canada Research Scholarship. M Goyal is a co-principal investigator of the Escape trial. M Goyal has also received a research grant from/is a consultant for/sits on the advisory board for Covidien. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Stroke-related disability remains an issue despite increasing use of IV tPA.

• Fast and complete reperfusion is an unmet need that endovascular therapy using retrievable stents is promising to overcome.

• Three recent randomized trials failed to show any benefit of endovascular therapy in acute stroke setting; other trials are currently enrolling.

• Time delay in achieving reperfusion was a common factor that influenced the recently neutral trials.

• While delays are inevitable, they can be minimized and overcome with efficient workflow.

• Health care providers should be mindful of the trade-off between advanced imaging and time loss.

• There is an increasing need for more data that will help identifying a universal time metrics in endovascular therapy.

Notes