International Stroke Conference (ISC)
February 11-13, 2015

February 13, 2015
Attendees of the 2015 International Stroke Conference were treated to the overwhelmingly positive results of ESCAPE, EXTEND IA and SWIFT PRIME this morning, building on the excitement generated by MR CLEAN for mechanical thrombectomy of proximal intracranial occlusions causing acute cerebral ischemia. Today will likely mark a dramatic shift in the perception of mechanical thrombectomy for proximal anterior circulation occlusions in previously well patients with adequate neuroimaging-selection, a critical mass of multidisciplinary stroke expertise and lighting-fast acute stroke workflow. One of the lead investigators of ESCAPE closed his remarks with the claim that intervention in the studied context is the new standard of care for acute stroke patients. For sure, these trials will not only serve as a foundation for efficacy of endovascular reperfusion therapies in carefully selected patients but also as a blueprint for running the acute evaluation and management aspects of a comprehensive stroke center as a tight ship.

At the expense of being overly negative concerning admittedly exciting data, “the studied context” has a lot of qualifiers.

How many of our patients are pre-morbid mRS 0-1, onset to treatment 110 minutes? Is that your average patient? Do you routinely get acute non-invasive angiography let alone score collaterals in your acute stroke patients? Can you mobilize your endovascular team within 1h of counseling/trial enrollment? Do you have software that provides you with a discrete visual and numerical representation of the penumbra? Do you only see anterior circulation strokes? What of the many, many patients that do not fall within the careful clinical and neuroimaging selection criteria of these trials?

To be sure, these encouraging data presented today are important for stroke patients and those who care for them. Even outside of the demonstrated efficacy, the dramatic results and surrounding pomp will shift the acute stroke treatment ethos in an appropriately aggressive direction; it’s good to win every once and again. However, we cannot lose site of the fact that these glowing results were in a highly-selected group of patients, nor can it be forgotten that the vast majority of these patients received full-stroke-dose alteplase prior to intervention. Broadly espousing “intervention is better than tPA” for acute ischemic stroke is a leap of faith, and “real world” treatment trials are still in need of development and recruitment; these data should not be considered definitive for the broad phenotypic spectrum of acute ischemic stroke nor should they hinder recruitment into future treatment trials.

– Mark N. Rubin, MD