Journal Jam 10 Part 2 Endovascular Therapy for Stroke

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-III

Broderick JP

2013



No benefit





MR RESCUE

Kidwell CS

2013



No benefit





SYNTHESIS

Ciccone A

2013



No benefit





MR CLEAN

Fransen PS

2014



13.5%  disability benefit





ESCAPE

Goyal M

2015



24%  disability benefit





EXTEND IA

Campbell BC    

2015     



31%  disability benefit





SWIFT PRIME    

Saver JL

2015



26%  disability benefit





REVASCAT

Jovin TG

2015



16%  disability benefit





THRACE

Bracard S

2016



11%  disability benefit





THERAPY

Mocco J

2016



8%  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.