Endovascular Treatment for Ischemic Strokes With Large Vessel Occlusion

Intravenous tissue-type plasminogen activator (tPA) has been the mainstay and only therapy with proven clinical benefit in patients with acute ischemic stroke for the nearly 20 years.1 Patients harboring a large vessel occlusions (LVOs) seemed to be recalcitrant to intravenous thrombolysis that portended a poor neurological recovery.2 Catheter-based treatments offered a promise of higher recanalization rates and better outcomes.Over 2 decades, there has been increasing operator experience and advances in technology allowing for efficient and effective removal of the offending thrombus. Three randomized controlled trials published in February 2013 failed to demonstrate the benefit of intra-arterial therapy (IAT) but had slow rates of recruitment, absence of mandating the presence of an LVO, prolonged times to IAT and use of older generation thrombectomy devices.3–5 This led to an initial dampening of enthusiasm followed by a resolve of the stroke community to press forward with clinical trials.The Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN)6 addressed several of the weaknesses of previous trials by enrolling only patients with a proven LVO in the anterior circulation, enrolling a high proportion of patients with more proximal occlusions of the carotid terminus and M1 MCA (91%) and achieving higher TICI 2b or 3 reperfusion rates as compared with recent studies. With 500 enrolled patients, 233 in the intervention (IAT) arm and 267 in the control (medical management of which almost 90% received IV tPA), the study showed a significantly higher proportion of patients achieving a good functional outcome with IAT as compared with medical management only, resulting in a 13.5% absolute difference points in …