Top Things to Know: Large-Core Ischemic Stroke Endovascular Treatment
Published: December 17, 2024
Prepared by Ashley Wagner, PA-C, Associate Science and Medicine Advisor
- This Science Advisory summarizes recent randomized trials on the efficacy of endovascular thrombectomy (EVT) in large-core ischemic stroke (LCIS), analyze the similarities and differences among these trials, and discuss the clinical implications of their findings.
- Until recently, most randomized clinical trials for EVT excluded patients with LCIS with the premise that reperfusion therapies would have low to no benefit.
- This Science Advisory examined 6 clinical trials with a total of 1887 patients that were randomized in a 1:1 ratio to either EVT or medical management (MM) to address 5 primary endpoints: functional independence, independent ambulation, symptomatic hemorrhage, decompressive craniectomy, and mortality.
- Significantly higher functional independence and independent ambulation rates were observed following EVT compared to MM.
- Symptomatic hemorrhage rates were relatively low for both the EVT and MM groups, with numerically but not significantly higher rates in EVT groups compared to MM groups.
- In the case of decompressive craniectomy and mortality, the data did not indicate a consistent advantage for either treatment approach.
- The combined analysis of all 6 trials (using the generic inverse variance method) produced a combined odds ratio (OR) of 1.57 (95% CI 1.40-1.76) favoring endovascular therapy.
- Future research includes examination of the mechanisms, recently completed trials, patient-level pooled clinical and image data, secondary endpoints, cost-effectiveness, impact of the degree of hypodensity, and underrepresented subgroups.
- The results from these six clinical trials examining the efficacy of EVT provide strong evidence of its benefit in patients who have good pre-stroke functional status and significant stroke severity with a LCIS on initial imaging.
- The results reframe current evidence regarding the role of reperfusion therapies in those with larger areas of presumed irreversible ischemia.
Citation
Gonzalez NR, Khatri P, Albers GW, Dumitrascu OM, Goyal M, Leonard A, Lev MH, Martin R, Tseng C-H; on behalf of the American Heart Association Stroke Council; Council on Basic Cardiovascular Sciences; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; and Council on Peripheral Vascular Disease. Large-core ischemic stroke endovascular treatment: a science advisory from theAmerican Heart Association. Stroke. Published online December 17, 2024. doi: 10.1161/STR.0000000000000481