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Issue: Issue 3 (2016) – Supplement 2


Lecture

Mechanical revascularization in acute stroke

Author(s):
Tiago Parreira
Abstract:
The year of 2015 was a hallmark for the treatment of acute stroke. The publication of the MR CLEAN trial elicited a cascade of positive results from six additional stroke randomized controlled trials: ESCAPE, EXTEND-IA, REVASCAT, SWIFT PRIME, THERAPY and THRACE, which were halted prematurely for efficacy. The cumulative evidence from these studies shows an overwhelming benefit from the endovascular treatment of intracranial large artery occlusions. The published trials led to guideline changes in the USA and Europe, which reflect the major common factors amongst studies, but the need for clinical judgment remains significant, especially in patients who do not neatly fit the patient population enrolled in the trials, but who probably also benefit from this treatment. All studies (with the exception of THERAPY) involved new generation devices, namely stent retrievers. Although most of the technical approaches, with some variations, are relativity standardized, many uncertainties remain for specific situations such as tandem occlusions or intracranial stenosis. The decision to use general anaesthesia or conscious sedation has also been the topic of much debate. Early studies showed worse outcomes associated with general anaesthesia but were confounded by indication, that is, medically unwell patients with poorer prognosis were more likely to undergo general anaesthesia. The MR CLEAN trial addressed this issue, and treatment effect was clearly greater in those treated under conscious sedation. The concern regarding thrombectomy costs has also been addressed. The studies concluded that, although the upfront costs of thrombectomy are high, the potential quality-adjusted life year gains mean this intervention is cost-effective.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):L6
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