STANDARDS FOR PROVIDING SAFE ACUTE ISCHAEMICSTROKE THROMBECTOMY SERVICES
14 May 2016
Stroke is the third leading cause of death and the leading cause of disability in Europe. The management of acute ischaemic stroke is a major healthcare challenge but improving outcomes for acute stroke patients offers major benefits to patients, healthcare systems and society as a whole.
The immediate aim of treatment of acute ischaemic stroke is to recanalise an occluded vessel as quickly, safely and effectively as possible so as to restore reperfusion to the ischaemic brain region. Currently the standard treatment for acute ischaemic stroke for patients presenting up to 4.5 hours after onset is intravenous thrombolysis using tissue plasminogen activator (IVT) . This treatment results in a recanalisation rate of only 50% of patients with distal vessel occlusions. However, recanalisation rates of large proximal vessel occlusion are disappointing at 24 hours after IVT treatment, with rates of 14% for internal carotid arteries and 35% for middle cerebral arteries being reported . Over one third of patients with anterior circulatory ischaemic stroke will have large vessel occlusion.
The prognosis for patients with clinically severe stroke secondary to proximal occlusion is poor with the NINDS trial demonstrating that only 10% of patients with an NIHSS score of 20 or more achieved independence at three months . Previous randomised controlled studies reported in 2013 (IMS III, MR RESCUE, SYNTHESIS Expansion) evaluating endovascular approaches in acute ischaemic stroke caused by large vessel occlusive stroke showed no additional benefit to endovascular approaches [3, 4, 5], however despite this in many locations outside the UK these procedures have been incorporated into usual clinical practice [6, 7].
Reasons for the neutral results include use of older, less effective recanalisation devices, longer time window from onset to intervention and the inability to effectively identify patients with large vessel occlusion with appropriate angiographic imaging in a timely fashion. The rationale to deploy endovascular therapies for ischaemic stroke is to potentially improve outcomes by facilitating early recanalisation of an occluded large artery as quickly as possible. Data from the IMS III study confirmed that time window for treatment is a crucial factor and subgroup analysis from this study suggested that improved outcomes (although not statistically significant) were observed in patients who received endovascular therapy within 90 minutes of IVT if thrombolysis treatment was commenced within 2 hours of stroke onset.
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