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Endovascular Stroke Treatment is Superior – Let’s Get to Work!
Stroke from blockage of major blood vessels, known as acute ischemic stroke, causes lasting brain damage and is devastating to patients. This type of stroke becomes a ready-made target for procedures that reopen the vessel and restore blood flow easily performed using “endovascular” (from within the blood stream) techniques. Cerebrovascular and endovascular neurosurgeons have long been at the forefront of these type of procedures.
Technical advances have allowed neurosurgeons, in particular, to deliver care more efficiently. These include endovascular devices such as stentrievers, suction aspiration devices, and clot retrieval devices, which allow rapid restoration of blood flow in blocked arteries in the brain.
Shockingly, three trials published just over two years ago — IMS III, MR RESCUE, and SYNTHESIS Expansion — almost brought these life-saving procedures to a halt when results questioned whether such procedures were effective. Fortunately, belief in their value led many to continue to probe the issue.
As Mark Twain once said, “All generalizations are false, including this one.” Fast forward to 2015, when a landmark trial from the Netherlands — aptly named MR CLEAN — definitively revealed that the addition of endovascular therapy improved functional outcomes when compared to treatment with medical treatment — including the intravenous clot buster, tPA — alone.
No less than five additional trials — ESCAPE , EXTEND-IA, SWIFT-PRIME and REVASCAT — have corroborated the positive results noted in the aforementioned MR CLEAN study. They all show conclusively that endovascular treatment for stroke is safe, and is superior, to the current standard of care in achieving best patient outcomes. Jointly, these trials put to rest the questionable results reported in the IMS III, MR RESCUE, and SYNTHESIS Expansion trials published in 2013, and validate the criticisms leveled towards their study design and execution.
Now that there is conclusive evidence that endovascular surgery offers significant advantages to those who suffer large vessel strokes, we need to collaborate to improve access to these treatments for stroke patients. A crucial factor to ensure that our patients receive timely treatment is to compel insurers to remove the “experimental” designation for these interventions. Insurer policies must change, and these procedures must be covered and paid for. Current appeal processes simply are not a feasible alternative in an emergent setting.
As cerebrovascular neurosurgeons, we are entering a new exciting era of stroke care. There are approximately 800,000 patients per year in the United States that suffer a stroke and the vast majority of these fit the criteria of these studies and as such would likely benefit from endovascular intervention. Resources and efforts must be directed toward creating regionalized stroke centers in order to bring high quality and comprehensive stroke care — including timely access to endovascular surgery — to our patients.
Guest Post from Clemens M. Schirmer, MD, PhD, FAANS, FAHA (left) AANS/CNS Cerebrovascular Section Wilkes Barre, PA and Henry H. Woo, MD, FAANS, FACS, FAHA (right) AANS/CNS Cerebrovascular Section Stony Brook, NY