New Interventional Stroke Trials

Excerpt

Endovascular treatment of acute stroke due to large vessel occlusion is undoubtedly extremely effective and nowadays the treatment of choice; however, looking at inclusion criteria of the large randomized clinical trials only highly selected patient populations were treated to demonstrate efficacy in these cohorts. In particular, patients with a poor overall prognosis, e. g. already large infarct reflected by a low Alberta stroke program early CT score (ASPECTS) at presentation or a high likelihood of a benign spontaneous course, e. g., low National Institutes of Health stroke score (NIHSS) at presentation, have either been excluded or are underrepresented in these studies. How should these patients now be handled in clinical practice? Can underpowered post hoc subgroup analysis of trials or observational single center studies be relied on to answer these questions? In the past, unexpected results were often experienced when data from non-randomized studies where later contradicted in randomized clinical trials. Are patients with large infarct cores at presentation really being helped or are the numbers of patients with high disability and a low quality of life just being increased? Moreover, the additional expenses spent on these procedures have to be justified. Likewise, are the outcomes in patients with a very low initial NIHSS compared to the spontaneous course really being improved or are they being exposed to unnecessary risks in view of the possible, although luckily rare complications associated with the intervention? …