Jose Gutierrez, MD, MPH

Containing the brain damage after an acute stroke has been an elusive goal and neuroprotective strategies have not been successful . In this article, Kasner et al. present results from a multicenter, international, randomized clinical trial of Transcranial Laser Therapy (TLT) for acute cortical stroke (NEST-2). The authors hypothesized that TLT would be associated with reduced cortical stroke volumes. They used predominantly brain CT to assess the infarct size, expressed in volume, and two other surrogates of infract size, ASPECTS and a modified ASPECT that reflects cortical involvement. 

The authors present data on 640 patients enrolled in whom TLT was provided 24 hrs after an acute stroke and neuroimaging was available at day 5 after the acute stroke. The authors did not find evidence that TLT was associated with smaller infarct size (in either volume or by the ASPECTS or modified ASPECTS scores). The primary analysis and the prespecified subgroup analyses (NIHSS > 10, syndromes localized to the anterior circulation were negative.

The lack of benefit of yet another therapy for acute stroke is distressing to the stroke community. Trials after trial have failed to improve the odds of recovery after stroke, with the exception of IV-TPA. So what is next? Is focusing in acute stroke treatment/recovery the best strategy to alleviate the societal burden that stroke represents?