COMMENTARY

A Transformation in Stroke Care

Mark J. Alberts, MD

Disclosures

February 13, 2018

Hello. I am Dr Mark Alberts, head of the department of neurology at Hartford Hospital in Hartford, Connecticut. Welcome to this Medscape stroke update.

I want to briefly discuss two major reports that came out of the 2018 International Stroke Conference held in Los Angeles, California, in January. One very important presentation related to the DEFUSE-3 study.[1] This was a prospective, randomized study comparing endovascular therapy versus no endovascular therapy, with a baseline of best medical therapy, in patients who had evidence of large artery ischemic strokes involving the internal carotid artery or middle cerebral artery territory and significant areas of mismatch as determined by the rapid imaging software.

This study was somewhat similar to the DAWN study,[2] which was presented at a stroke conference in Europe in May 2017. The patients in DEFUSE-3 had evidence of a large artery, middle cerebral artery territory stroke, with average NIH stroke scale scores of about 16, but with relatively small areas of core infarction; the average was about 9 mL. Patients in the experimental group were treated with various types of stentrievers versus patients in the control group who received medical therapy.

About 45% of patients treated with endovascular therapy achieved a good functional outcome at 3 months versus about 17% of those who received only medical therapy. The odds ratio was about 2.7 in favor of endovascular therapy compared with best medical therapy alone. In general, other endpoints, such as hemorrhagic stroke, death, and so on, were either similar or favored endovascular therapy.

With DEFUSE-3, with a time window of 6-16 hours, we now have a study that confirms the results of DAWN, with a time window of 6-24 hours, showing that endovascular therapy is amazingly effective in terms of improving functional outcomes compared with best medical therapy alone. I believe that the combination of DEFUSE-3 and DAWN results is transformational; it says that within 16-24 hours of stroke, patients still have a lot of salvageable tissue and should be treated with endovascular therapy.

Another major event at the International Stroke Conference was the release of new guidelines for the treatment of acute ischemic stroke.[3] These guidelines included dozens of recommendations, but a few of them are somewhat problematic, in my opinion and that of at least some of my colleagues. This includes recommendations that MRI and CT angiography (CTA) may not be that helpful in the acute management of patients with an ischemic stroke.

I find this troubling and problematic because MRI and CTA have been instrumental in advancing stroke care, improving our diagnostic abilities, and guiding further therapy for secondary prevention and for the workups in many, many patients with ischemic strokes. We can all think of examples where these tests have been quite useful for diagnosing such things as venous thrombosis, arterial dissections, and strokes in different vascular territories, perhaps due to a vasculitis, which would not have been appreciated without advanced imaging with MRI or CTA.

Although these modalities may not affect every patient with ischemic stroke and may not change the outcomes of every patient with ischemic stroke, I and many of my colleagues believe that these imaging techniques are highly effective for establishing an accurate diagnosis, planning for further diagnostic testing, and for initiating therapies for secondary prevention.

Many other advances were announced, but these are two major ones that I wanted to share with you today. Thank you very much for tuning in and listening to my updates. Have a good day.

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