Endovascular Therapy in Stroke: Much Evidence and Few Trained Operators

Endovascular therapy is now considered as the standard of care for acute ischemic stroke caused by large vessel occlusion. The time between symptoms onset and reperfusion emerges as the most determinant factor for good clinical outcomes, much more strongly than even in acute myocardial infarction. The saying “time is brain” is even more relevant than “time is myocardium.” Sites with trained interventional neurologists are scarce all over the world, something that prompts the following spontaneous question: should we, interventional cardiologists, be involved in the treatment of stroke?

While the discussion continues, we should at least be informed on this subject matter, so as to be ready to eventually go into the cath lab.

This study developed a score to predict which patients would benefit the most from endovascular therapy, fundamentally targeting variables easy to analyze: age and stroke severity.

Researchers analyzed a total of 4079 patients admitted with acute ischemic stroke, who were included in the Paris Stroke Consortium registry. A score was developed based on age (1 point per decade ≥50 years of age) and severity (2 points per every 5 points on the National Institutes of Health Stroke Scale [NIHSS]). Its aim was to predict spontaneous prognosis. The primary outcome was an improvement in the modified Rankin Scale at 90 days after endovascular therapy in patients with low, intermediate, or high scores.

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In patients who did not undergo endovascular treatment, scores <8 were predictive of good outcomes (Rankin Scale score: 0–2), whereas scores >12 were predictive of much poorer outcomes (Rankin Scale score: 4–6).

Endovascular therapy was associated with better outcomes in patients with scores >12 (p < 0.001) and intermediate scores (between 8 and 12), but not in patients with low scores (<8).

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If interventional cardiologists intend to get involved in the treatment of these patients, they should receive training on the assessment of these scores (the NIHSS, for starters) and of imaging scans (computerized axial tomography, nuclear magnetic resonance), and, of course, on actual endovascular therapy techniques.

Conclusion

Patients admitted with acute ischemic stroke can be stratified with this new, easy-to-calculate score. Patients who are older and with more severe stroke will benefit the most from endovascular therapy, while patients who are younger and with less severe stroke will derive no benefit from it.

Original title: Efficacy of Endovascular Therapy in Acute Ischemic Stroke Depends on Age and Clinical Severity.

Reference: Raphaël Le Bouc et al. Stroke. 2018 Jul;49(7):1686-1694.

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