Endovascular therapy was a "game-changer" in stroke in 2015, leading specialists told 51˶.
Beginning in January with the trial, through June with the publication of and , multiple studies demonstrated that thrombectomy outperformed tPA alone in boosting 90-day functional independence by 13.5% to 31%.
in the New England Journal of Medicine called it a "sea change" and added, "It's about time."
In response to the question of what was the biggest clinical advance of 2015, six of seven leading stroke specialists agreed: endovascular therapy.
The response on stroke came from a survey of 55 neurologists, asking their opinions on the biggest clinical advance in their subspecialty. The "game-changers" selected in five major subspecialties were:
1. MS: Ocrelizumab results in ORATORIO and OPERA I and II
2. Stroke: Thrombectomy for acute ischemic stroke
3. Parkinson's disease: New therapies for delivering carbidopa/levodopa
4. Sleep: SERVE-HF trial showing adaptive servoventilation increased mortality
5. Alzheimer's disease: No single clinical advance stood out
Questions over optimal stroke therapy had persisted since three trials in 2013 suggested endovascular therapy was no more effective than intravenous tPA alone. But all that changed this year.
"Mechanical thrombectomy for acute ischemic stroke is a once-in-a-generation breakthrough in care," said , director, UCLA Comprehensive Stroke Center and first author of the SWIFT-PRIME trial.
"More patients will be going home free of disability after large ischemic strokes than ever before," said , chair of neurology and director of the Cedars-Sinai Stroke Center in Los Angeles.
And , director of the University of Cincinnati Neuroscience Institute, labeled it the "biggest change in acute stroke therapy since tPA approval for stroke in 1996."
The breakthrough of thrombectomy came about, experts say, because of several factors: improvement in technology of the stent receiver device which can achieve more complete recanalization; improved workflow efficiencies producing faster door-to-treatment times; and change in neuroimaging criteria for identifying large vessel occlusions.
The positive results of these trials is now leading to new questions about ways to improve treatment.
In imaging, said , director of the Oregon Health & Science University Stroke Center in Portland, "Advances in imaging technology now allow us to identify patient's that can still benefit from thrombectomy even if they are past eight hours due to 'waking up' with their symptoms."
, vice president for Neuroscience, University of Kansas Medical Center, believes the field now faces a number of important questions about imaging: "Can (we) select cases likely to have a good outcome with EVT based on imaging criteria and potentially expand the number of eligible cases well beyond the usual time window? What imaging criteria should be used? Are imaging criteria the best way to select appropriate cases for EVT?"
Also, access to endovascular therapy is currently a limiting factor. It "needs to be given in advanced centers with clinical expertise and the necessary acute and post-treatment support structure," said, Ruth L. Works professor and chair of neurology, University of Kentucky. But these patients cannot be easily transported to the centers. "It remains to be determined how best to integrate this approach into overall systems of care on a regional and state-wide basis," he said.
Lyden says possible solutions are novel approaches for triage in the field including "new paramedic tools; in-ambulance telemedicine; or even the mobile stroke units that contain a CT scanner on the ambulance."