The Latest in Acute Stroke Management--A Conversation

Mark J. Alberts, MD; Werner Hacke, MD, PhD, DSc; Helmi L. Lutsep, MD; Bret S. Stetka, MD


April 02, 2015

In This Article

Editor's Note: At the International Stroke Conference (ISC) 2015, held in Nashville, Tennessee, in February, data from several dramatically positive, potentially practice-changing acute stroke trials were reported. Medscape recently interviewed stroke experts Dr Mark Alberts, Dr Helmi Lutsep, and Dr Werner Hacke about the implications of these findings and about the latest in acute stroke management.


Medscape: To begin, what were the major findings—those likely to have the most clinical impact—presented at the ISC this year on acute stroke management?

Helmi L. Lutsep, MD: The major findings presented this year at the ISC on acute stroke management are without a doubt the results of four randomized endovascular therapy trials: MR CLEAN,[1] ESCAPE,[2] EXTEND-IA,[3] and SWIFT PRIME.[4] These trials each showed that in patients with acute ischemic stroke caused by a proximal vessel occlusion, endovascular treatment improved functional outcomes.

Mark J. Alberts, MD: I agree with Helmi's perspective. Going forward, two significant challenges in stroke management will be: (1) screening a lot of patients to define which specific patients require endovascular therapy; and (2) the timely transfer or transportation of such patients to comprehensive stroke centers for such therapy. One of the endovascular studies[3] had to screen almost 8000 patients to find 75 or so who benefited from this therapy. This means to me that we must do a better job with triage and initial screening.

Werner Hacke, MD, PhD, DSc: I would like to add that the reported results only apply in a minority of stroke patients—those with large proximal vessel occlusions (eg, terminal carotid and proximal middle cerebral arteries) successfully treated within 6 hours. Also, the results only apply to treatment with stent retrievers, not to treatment with other revascularization devices (not yet, anyway).

It is unclear how many stroke services we will need to offer the studied treatment to all patients who are candidates. I prefer that this endovascular therapy is carried out at large stroke centers that do more than 100 interventional stroke therapies per year over small or single-person centers that only do 10 or 20 cases a year. Quality comes with large numbers. Perhaps one large-volume comprehensive stroke center (CSC) per million-person catchment area is adequate. Tele-neurology and the "drip-and-ship" approach should also be reinforced. [Editor's note: the "drip-and-ship" paradigm in stroke care refers to the practice of administering intravenous (IV) recombinant tissue plasminogen activator (rt-PA) at the emergency department of a community hospital followed by transfer to a CSC.]


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