Convincing Evidence for the Role of Endovascular Neurosurgery for Acute Ischemic Stroke

Brian L. Hoh, MD

From the Cerebrovascular Section

 

The Cerebrovascular Section had an outstanding meeting February 9–10, 2015, in conjunction with the International Stroke Conference, February 11–13, in Nashville. With nearly 500 participants in attendance, the meeting highlighted exciting landmark clinical trials that will significantly impact the field and the future of neurosurgical treatment for stroke.

Four multicenter prospective randomized clinical trials (MPRCTs) demonstrated the superiority of endovascular intervention over standard care for the treatment of acute ischemic stroke patients with large vessel occlusion. These clinical trials are MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times), EXTEND-IA (Extending the Time for Thrombolysis in Emergency Neurological Deficits—Intra-Arterial), and SWIFT PRIME (Solitaire™ FR With the Intention For Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke).

As a society meeting at the forefront of late-breaking science in the field, the Cerebrovascular Section held a symposium of PIs from each of the four trials on February 9. Later in the week, PIs from the trials presented their results at the International Stroke Conference.

Prior to these trials there had been a paucity of Level 1 evidence demonstrating the superiority of endovascular intervention over standard care for acute ischemic stroke patients and, in the minds of some in the field of stroke care, clinical equipoise regarding this question. With four MPRCTs now demonstrating that acute ischemic stroke patients with large vessel occlusion who undergo endovascular intervention are significantly more likely to achieve independent functional outcomes than patients who receive standard care, there is convincing evidence that endovascular intervention has a critical role in the treatment of acute stroke.

The meeting was held in collaboration with the Society for Neurointerventional Surgery (SNIS) and the Vascular Section of the European Association of Neurosurgical Societies (EANS). Current scientific controversies were debated at the Cerebrovascular Section meeting, including the debate over unruptured brain AVM treatment versus observation, EC-IC bypass versus flow diversion for giant aneurysms, direct versus indirect bypass for moya moya disease, and surgery versus radiosurgery for brainstem cavernous malformations.

It is clear that this is an exciting and groundbreaking time for cerebrovascular and endovascular neurosurgery. In my chair’s address at the Cerebrovascular Section meeting, I quoted Dr. James Robertson’s 1975 Congress of Neurological Surgeons Presidential Address (Dr. Robertson was also the eighth chair of the Cerebrovascular Section in 1982–1983):

“In summary, there are many unanswered problems in stroke therapy. These comments are presented to stimulate interest and provoke an aggressive approach to stroke therapy by neurosurgeons. There is no doubt that the quality of life can be improved by extracranial and possibly extracranialintracranial bypass vascular surgery. Prevention of stroke and extended longevity may be forthcoming by the use of platelet-inhibiting drugs. The main issue, the central plea, is that neurosurgeons lead the way.”

Those sentiments remain true to this day. The Cerebrovascular Section continues to actively promote neurosurgery’s leadership in stroke therapy.

FOUR MULTICENTER PROSPECTIVE RANDOMIZED CLINICAL TRIALS (MPRCTS) DEMONSTRATED THE SUPERIORITY OF ENDOVASCULAR INTERVENTION OVER STANDARD CARE FOR THE TREATMENT OF ACUTE ISCHEMIC STROKE PATIENTS WITH LARGE VESSEL OCCLUSION.