Endovascular Stroke Management: Key Elements of Success

In the last 12 months, treatment of acute ischaemic stroke secondary to large vessel occlusion has undergone a paradigm shift. The success of endovascular surgery, and in particular, the use of stent-retrievers, is remarkable.

Beyond percentages and p values, the endovascular trials demonstrated, in their similarities and their differences, the critical elements of successful intervention in acute ischaemic stroke. Patient selection based on non-invasive neuroimaging has emerged as a critical step in acute ischaemic stroke management. The more sophisticated imaging-based selection, those assessing collateral blood flow or ischaemic penumbra appear to be associated with better outcomes and possibly fewer complications. The importance of achieving effective, quality reperfusion is also demonstrated, in a remarkably linear fashion, across the 5 published trials. This may emerge as the single most important determinant of functional outcomes. While reperfusion may succeed time as the preeminent modifiable variable, it remains clear that achieving quality reperfusion in a timely manner should remain the goal of all acute stroke programs.

Comparing the recent successful endovascular stroke trials, both between one another, and to their unsuccessful predecessors, emphasizes the importance of patient selection, time and reperfusion. Highlighting these factors allows for a better understanding of the challenges facing clinicians and the changes required to be made in hospital systems in order to achieve a new standard of care in treating acute ischaemic stroke.