Public Health Urgency Created by the Success of Mechanical Thrombectomy Studies in Stroke

L. Nelson Hopkins, David R. Holmes
2017 Circulation  
S troke is a major cause of death and disability. 1 Each year, >15 million strokes occur worldwide. In addition, ≈35% of strokes are caused by potentially reversible large-vessel occlusion. Until 2015, no scientifically proven interventional treatment strategies were available to address this type of stroke. In the early 1980s, reports of dramatic clinical improvement with reopening of large-vessel occlusions were published. However, patient volumes were small, tools were crude, and results
more » ... inconsistent. The first significant advance in the treatment of this condition was the US Food and Drug Administration's approval of intravenous tissue plasminogen activator in 1996. With tissue plasminogen activator, only a small subset was eligible for this therapy, and most people with major strokes fared poorly. 2 Subsequent development of the Merci device (Stryker) gave birth to the field of invasive clot retrieval for acute ischemic stroke (AIS). MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) first documented transformational beneficial results for clot retrieval. 3 This study was followed by 4 more positive trials reported in 2015 and began a new era in stroke care. 3 The new data have resulted in a potentially cataclysmic gap between patient need and available expertise. Given the recent study results, the "gold standard" treatment is now rapid mechanical revascularization and mirrors the last 2 decades of acute myocardial infarction care. In contrast to acute myocardial infarction, however, we now face an overwhelming shortage of neurointerventionists to support the shift in AIS treatment. Therefore, we believe interventionists from other training backgrounds must now fill this gap in AIS, and a collaborative ST-segment elevation myocardial infarction (STEMI) model for care needs to be instituted to ensure rapid revascularization. Brain cells appear to be even more sensitive to ischemia than is the myocardium. A subset analysis of recent trials shows that time to intervention is critical with patients revascularized ≤2 hours achieving ≈90% good functional neurological recovery, whereas the recovery associated with a delay of >6 hours was considerably less, yielding ≈20% good functional recovery. 4 We envision a multidisciplinary approach that includes cardiologists for optimal results. "Time is Brain" must be the mantra, so immediate revascularization must be the goal. As reimbursement for revascularization improves, technology offerings will rapidly advance, making optimal intervention for AIS more widely available, efficient, and successful. Available interventional expertise to ensure rapid intervention will be key to good outcomes, with fast-track protocols in emergency rooms, prompt and accurate image-based diagnosis (ischemic occlusion versus hemorrhage), appropriate patient selection, and postoperative care necessary for best outcomes. Although the concept of comprehensive stroke centers has been developed and implemented in selected areas of the country, the centers are usually located in major metropolitan areas. The composition of these centers includes neurora-
doi:10.1161/circulationaha.116.025652 pmid:28348088 fatcat:sjmed3x3hjaink6uc7kz7cadjy