Vikas Pandey, MD
Endovascular therapy has always been a promising and alluring option during acute ischemic strokes given the rather basic principle that if there is a clot in the cerebral vessels affecting perfusion to a region of the brain, manually removing this clot should prevent further ischemia and provide overall benefit to the patient. The harsh reality is that due to quantifiable factors such as time from symptom onset and to recanalization, variably interpreted factors such as amount of penumbra and early ischemic changes on CT, and as of yet unknown factors such as genetics, persistence and efficacy of collateral circulation and other reactions occurring at the biochemical level, the overall advantage of endovascular therapy has been difficult to ascertain. The publication of randomized trials in 2013 showing no added benefit of intra-arterial fibrinolysis called into question whether such therapy should be further supported by medical centers or reimbursed by third-party payers. However, recent trials such as MR CLEAN and ESCAPE have again shifted the landscape toward endovascular therapy and its benefit in lowering stroke disability and morbidity.
To gain knowledge into how endovascular therapies have been utilized, and the clinical outcomes resulting from these procedures, the group from across the US and Canada set out to review the Get With The Guidelines Stroke data from 1087 hospitals from 2003 to 2013. The type of endovascular therapy has evolved over time from initially being more geared toward intra-arterial fibrinolysis and angioplasty/stenting to later on in the data set where techniques of mechanical clot and stent retrievers were used. The authors found that 454 hospitals (41.8%) provided endovascular therapy to at least one patient during the study period and that a total of 1.6% of all ischemic stroke patients received endovascular therapy. During the same period, 8.0% of all of the ischemic stroke patients received IV TPA alone without endovascular therapy. In general, there was an increase over time of the proportion of hospitals providing endovascular therapy from 2003 to 2012, with a drop in 2013. Along the same lines, the proportion of patients treated with endovascular therapy at hospitals providing this therapy increased from 0.7% to 2% from 2003 to 2012, with again a drop in 2013. Clinically, mortality was lower in hospitals that offered more endovascular therapy and there was a decrease over time of in-hospital mortality (29.6% in 2004 to 16.2% in 2013). There was also a decrease in symptomatic ICH and increase in independent ambulation over time.
The data shows that endovascular therapy has been trending toward decreased in-house mortality and improved patient outcome and this has been finally exemplified in the newer interventional trials. The slight drop in endovascular utilization in 2013 can be correlated to the publication of the negative interventional trials, but now that trial data has been published to the counterpoint, an expected upswing in utilization for centers that already have the means of endovascular therapy and a clamoring for biplane angiography suites and interventionalists is sure to follow. The question no longer is if endovascular therapy is beneficial, but rather for who is endovascular therapy the most beneficial and it is this process of patient selection on the basis of viable penumbra tissue, presence of good collateral circulation, and systems-based changes to ensure the fastest door to groin/recanalization times that will cement assessment for endovascular treatment as a necessity for every acute ischemic stroke that comes into the hospital.
Posted by Vikas Pandey (@DrVikasNeuro)