Recent trials have shown that endovascular treatment improves outcomes in patients with ischemic strokes secondary to proximal arterial occlusion. REVASCAT trial investigated the benefit of endovascular therapy versus best medical therapy alone. This study was undertaken in Catalonia, Spain where a mandatory registry (SONIIA) was initiated to monitor reperfusion therapy quality. This registry, since 2011, captured clinical data and outcomes on all ischemic stroke patients undergoing reperfusion therapy (IV TPA and/or endovascular treatment), including those in the REVASCAT trial. In this study, the authors used data from the registry and the trial to assess endovascular treatment and compared outcomes of patients treated within and outside of the trial.

In the 2 years of REVASCAT enrollment, 17596 ischemic strokes occurred; of which, 206 were included in the trial (103 in each arm). Of the 2576 patients receiving reperfusion therapies, 21% underwent endovascular therapy (n=540). Therefore, 437 endovascular treatments were performed outside of REVASCAT. 340 patients were ineligible for the trial due to various reasons: treatment later than 8 hours, age, M2 occlusion, and basilar artery occlusion. Of the 97 eligible patients, 67 were treated at REVASCAT hospitals and had other exclusions not captured by the registry. Procedural results were similar between eligible and ineligible patients. The 3-month functional outcomes were similar and superior compared to the medical arm of REVASCAT trial.

Outcome was similar within ineligible patients, which substantiates the value of endovascular treatment on a wide range of stroke patients and not just to those included in the recent trials. This data suggests that the current inclusion criteria for endovascular treatment may be too stringent and patients who would otherwise be deemed ineligible may potentially benefit. This is important to remember as our experience and expertise with endovascular treatment expands, additional patients could be considered. To truly determine efficacy, prospective trials would need to be conducted. Furthermore, this study has implications on healthcare systems. The utilization rate of endovascular treatment in Catalonia was 4.3/100,000 which correlated to 4% of all ischemic strokes during a 2 year period. If the scope of endovascular treatment were to broaden, stroke systems of care would need to be become more coordinated and efficient to allow for an increase in volume.