Over the last 2 years, the world of stroke treatment has completed a 180-degree turn, akin to what some may refer to as the 4-minute mile in terms of accomplishments by recent clinical trials. Interventions with intravenous tissue plasminogen activator (IV-tPA) and intra-arterial procedures have demanded tremendous changes in the treatment of acute stroke as health care providers rapidly adapt to new, innovative protocols.
Recent clinical trials, including MR CLEAN1, EXTEND-IA2, AND ESCAPE3 all point to the advantages of combined IV-tPA and intra-arterial (IA) intervention over IV-tPA alone in the treatment of acute stroke scenarios. However, this was not always the case. In 2013, both the IMS-34 trial and the SYNTHESIS5 trial demonstrated that there was no significant benefit for IA intervention over IV-tPA use in acute stroke except for a small, select group of patients with elevated NIHSS scores. However, in 2014, the MR CLEAN trial overwhelmingly confirmed that combined IA intervention and IV-tPA worked effectively. The results led to the accelerated proliferation of interventions in both the U.S. (14,000 interventions in 2014) and Europe (2,000 in Netherlands, 6,000 in Germany in 2014).
Additionally, multiphase CT angiography, which examines collaterals that are involved in supplying the ischemic area, has emerged as a prominent development for evaluating patients for IA intervention. A study published in 2015 in Radiology6 indicated a positive use for multiphase CT angiography in the evaluation of acute stroke for lA intervention. Ultimately, multiphase CT angiography may be a good predictor for outcome of IA intervention.
With the efficacy of IV-tPA and IA intervention continuing to be proven, much attention has turned to time to treatment, or “door to needle” time as a critical metric of success in stroke treatment.
Front-end protocols essential for timely stroke treatment were a main focus during the Society of Vascular Interventional Neurology meeting, which took place October 15-18, 2015. Hospital emergency departments and stroke teams shared novel front-end protocols being used to evaluate patients in the field by emergency medical services personnel, as well as rapid assembly of stroke teams in the emergency department in order to start treatment with IV-tPA in a safe but more rapid fashion, including triaging patients for IA intervention.
There was also extensive discussion among stroke centers, from community hospitals to large university complexes, regarding “pre-notification,” in which nurse practitioners and/or physician assistants are trained to evaluate stroke patients with NIHSS and ASPECTS scores and CT scans and administer IV-tPA with an off-site neurologist. These health care providers are needed to address the shortage of neurology and stroke specialists in rural areas.
With the continued development of new technologies and a team-focused approach to acute stroke treatment, the subspecialty of vascular neurology will continue to evolve and grow.
- Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11-20.
- Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009-18.
- Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019-30
- Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013;368(10):893-903.
- Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904-13.
- Menon BK, D’esterre CD, Qazi EM, et al. Multiphase CT Angiography: A New Tool for the Imaging Triage of Patients with Acute Ischemic Stroke. Radiology. 2015;275(2):510-20.