Sebina Bulic, MD
Dr. Abilleira and colleagues used data from a mandatory, population-based registry, which assesses reperfusion therapies for consecutive AIS patients for period 2011-12 in Catalonia. Catalonia stroke network includes 17 hospitals, 7 Comprehensive Stroke Centers, 7 Primary Stroke Centers and 3 community hospitals operating on a telestroke system. IV thrombolysis is offered at all sites and endovascular treatment is offered at Comprehensive Stroke Centers.
536 patients underwent EVT. Mechanical thrombectomy was done in 90.5% patients, 7.5% had combined approaches and 2.0% had intra-arterial thrombolysis. Median baseline NIHSS was 17.5 (13, 21) with occlusion level 87.9% in anterior circulation, specifically 6.6% proximal ICA, 16.6% distal ICA and T-ICA, 12.1% tandem occlusions, 52.4% M1 occlusions, 12.1% M2 occlusions and 0.2% A1 occlusion. Posterior circulation strokes occurred in 12.1% patients. 53% of patients received prior IVT. 73.9% achieved TICI IIb and III scores. Symptomatic bleedings were observed in 5.6% patients. At 3months, 22.2% patients were dead and 43.3% of all patients achieved a good functional outcome mRS <=2. Revascularized group showed higher rates of functional independence at 3 months. (53.5% vs. 14.3%; p< 0.001). Lower mortality rates at 3 months were seen in patients with anterior circulation strokes and among those ≤ 80 years. Stroke severity (NIHSS> 14), hypertension and age > 80 years showed a deleterious, independent effect. Coexistence of atrial fibrillation doubled the chances of being independent at 90 days. Interestingly, this study did not show an association between prior IVT and better outcomes.
Unfortunately, specific details of the endovascular procedure such as the use of antithrombotic medication during the procedure, the brand name of the mechanical device were not recorded. Also, as recognized by authors, a key limitation of this study is the absence of a contemporary control group.
Endovascular therapy is now used routinely foracute ischemic stroke. Having Class I Level A evidence proving its efficacy would be wonderful, but is it possible to conduct prospective randomized trial in which patients that would clearly benefit from endovascular therapy would be denied such treatment if randomized in no treatment group? I would be very reluctant to do so, but without randomization of all patients with ischemic stroke any further attempt for clinical trial is destined to fail. This study just confirms my belief that well run registries collecting data from all patients with endovascular therapy and carefully measuring outcomes would be reasonable alternative.