COMMENTARY

2014's Advances in Stroke

Mark J. Alberts, MD

Disclosures

January 09, 2015

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Hello. My name is Dr Mark Alberts, vice-chair of neuroendocrine at UT Southwestern Medical Center in Dallas, Texas. Today I would like to present an end-of-year summary of some of the most exciting developments in vascular neurology. Because of time constraints, we can't talk about all of the major advances in 2014. Here are some key ones.

A major development has been the very positive results of several studies of endovascular therapy for acute ischemic stroke. They have been reported at meetings and published in abstract form. These include MR CLEAN (Multi center Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands),[1] ESCAPE (Treatment for Small Core and Proximal Occlusion Ischemic Stroke, SWIFT PRIME (Solitaire™ FR as Primary Treatment for Acute Ischemic Stroke, and perhaps one or two others.

All of the studies looked at patients with acute ischemic strokes, some of whom got IV recombinant tissue plasminogen activator (rt-PA), some of whom did not. But the investigators all used an endovascular therapy approach which focused on using this new generation of stent retrievers to rapidly, safely, and effectively remove the clots and reperfuse the brain.

Typically, the patients had lesions in the distal carotid artery or proximal M1 or M2 artery. What the studies found is that using the stent retrievers, the operators were able to more rapidly reperfuse the brain, with fewer bleeding and other complications, and that reperfusion led to improvements in clinical outcome.

Now, so far as I can tell, none of these studies have been published in the peer-reviewed literature, but several of them will be published in the very near future. If the results are really as positive as have been recorded at various meetings, I think this is a major paradigm shift because it now proves—from different centers in different parts of the world—that this acute endovascular therapy is safe and effective for patients with large-vessel ischemic strokes. We will have to see how this plays out, but it appears that this will be another important tool in our treatment armamentarium for patients who either did (or in some cases could not) get IV rt-PA.

One of the limitations of that use of stent retrievers is that it cannot be done at all medical centers. To do it safely and effectively, it takes more than just an interventionalist. It really takes a diagnostic team of vascular neurologists, neuroradiologists, and the neuro critical care folks to take care of these patients before, during, and after the procedure. Overall, I think this is a very positive and hopeful development.

I would also like to briefly touch on another series of reports. These trials looked at the efficacy of implantable monitors to detect atrial fibrillation in patients with cryptogenic stroke. A major one of these, published by Dr Sanna and colleagues[2] in the New England Journal of Medicine this summer, looked at hundreds of patients with cryptogenic stroke to compare implantable rhythm monitor with no implanted monitor in the control group. (For full disclosure, I was an investigator in that CRYSTAL AF study, but I did not receive any compensation for my participation.)

What the study found was that at 6 months, the rate of detection of AFib was 9%. At 12 months, the rate of detection of AFib was 12.4%. And at 3 years, the rate of detection was 30%, so this shows that these implantable rhythm monitors are really very effective at picking up cryptogenic stroke.

Furthermore, the median time each day during which folks were in AFib was only 4.3 minutes. Certainly, in many of these patients, the fibrillation would never have been detected using routine ECG monitoring.

So, those are some of the key developments of 2014. There may be another Medscape report if something else pops up, but that is it for now. I look forward to your comments, and I wish everybody a happy and healthy new year. Thank you.

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