Endovascular procedures no better than medical care for acute strokeBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f877 (Published 13 February 2013) Cite this as: BMJ 2013;346:f877
Endovascular treatment of acute ischaemic stroke failed to improve outcomes for patients in a trio of recent trials, and a linked editorial calls for a moratorium pending further evaluation (doi:10.1056/nejm1215730). Treatments such as clot disruption or retrieval and intra-arterial thrombolytics are already licensed and widely used in the US, writes the author. Many providers and patients believe they work. Recruitment to further trials will be difficult unless federal insurers Medicare withdraw reimbursement for endovascular procedures used outside randomised trials⇑.
The first trial compared endovascular treatment head to head with intravenous tissue plasminogen activator (t-PA) in patients presenting within 4.5 hours of an acute ischaemic stroke. The second compared endovascular treatment after intravenous t-PA with intravenous t-PA alone in patients presenting within three hours. Those who had endovascular procedures were no more likely to survive 90 days with little or no disability than controls in either trial. Roughly 6% of all patients had symptomatic intracranial bleeding, regardless of treatment.
A third trial explored whether arterial embolectomy could help subgroups of patients presenting within eight hours, who had more or less salvageable tissue around their cerebral infarct. Embolectomy did not reduce the risk of death, disability, or intracranial haemorrhage compared with standard medical care in patients with or without an ischaemic penumbra on brain images.
Better thrombolytic drugs and better endovascular devices are already in the pipeline, says the editorial. These three negative trials may help restore clinical equipoise enough to evaluate them properly. Intravenous t-PA should remain the first line treatment for now.
Cite this as: BMJ 2013;346:f877