07 Mar Skilled Team Work Required For Endovascular Treatment of Ischemic Stroke
MedicalResearch.com Interview with:
Michael D Hill, MD MSc FRCPC
Calgary Stroke Program
Professor, Dept Clinical Neurosciences
Hotchkiss Brain Institute
University of Calgary, Cumming School of Medicine
Foothills Hospital, Calgary, Canada
Medical Research: What is the background for this study? What are the main findings?
Dr. Hill: Major ischemic stroke with blocked proximal arteries results in 60-80% death and disability. Recent studies of endovascular treatment were neutral. Evolution of technology has resulted in advances in the devices. Key features of past trials of endovascular therapy were, underdeveloped imaging paradigms for patient selection, slow treatment times and poor reperfusion rates.
Medical Research: What should clinicians and patients take away from your report?
Dr. Hill: Simply, endovascular therapy for major ischemic stroke over and above best medical care (ie. IV tPA) is effective . It reduces disability and saves lives. The NNT is very low 4, making it one of the largest proven effect sizes in all of medicine. BUT, it applies only under selected conditions.
First, you need a team. This means a stroke team, from pre-hospital, ED physicians and nurses, neuroradiology support, stroke neurology, stroke intervention and the stroke unit and rehabilitative support. Without the team this therapy does not work. All patients who are eligible should rapidly receive intravenous tPA.
Second, you must image the patients to select those who will benefit from therapy. You must demonstrate a small core, a blocked intracranial large artery and evidence of good collateral flow. You must do this very fast.
Third, you must act very quickly . This is where the team comes in. Imaging (CT) to groin puncture time should be less than 60 minutes and imaging (CT) to reperfusion time should be less than 90 minutes.
And finally, you should use the available novel technology to get the artery completely open.
I must emphasize that it is the triad of imaging, speed and reperfusion, performed by a team that will work. This is what we have shown in ESCAPE. It is and was a huge team effort.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Hill: Key issues to resolve are:
(1) What is the best imaging paradigm to select patients?
(2) 45% of patients still did poorly. How do we improve the therapy for them?
(3) How do we improve the procedure to get the reperfusion rates from 80% to 99%.
(4) How do implement this therapy? What is the best way to triage stroke patients to the right centre to the right team in the right timeframe to get this therapy?
Citation:
Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke
N Engl J Med 2015; 372:1019-1030 March 12, 2015
MedicalResearch.com Interview with: Michael D Hill, MD MSc FRCPC (2015). Skilled Team Work Required For Endovascular Treatment of Ischemic Stroke
Last Updated on March 7, 2015 by Marie Benz MD FAAD