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Year : 2014  |  Volume : 62  |  Issue : 4  |  Page : 474-

Endovascular treatment of acute ischemic stroke: Not yet a panacea for all troubles

R Rajan, D Khurana, R Rajan, D Khurana 
 Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
R Rajan
Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
R Rajan
Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh
India




How to cite this article:
Rajan R, Khurana D, Rajan R, Khurana D. Endovascular treatment of acute ischemic stroke: Not yet a panacea for all troubles .Neurol India 2014;62:474-474


How to cite this URL:
Rajan R, Khurana D, Rajan R, Khurana D. Endovascular treatment of acute ischemic stroke: Not yet a panacea for all troubles . Neurol India [serial online] 2014 [cited 2020 Jan 27 ];62:474-474
Available from: http://www.neurologyindia.com/text.asp?2014/62/4/474/141298


Full Text

Sir,

We read with interest the article "Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center" by Huded et al. [1] The authors present impressive data on outcomes following endovascular treatment in acute stroke. As rightly indicated by the authors, delay in reporting to a healthcare facility is a major hurdle in management of acute stroke in the Indian setting. However, we are unsure whether endovascular therapy is the right solution to this problem.

One of the important lessons learned from IMS-3 was that functional benefit was noted in those who received IV thrombolysis within the recommended window period regardless of whether they received endovascular therapy. [2] Hence, the emphasis is still on providing IV thrombolysis to eligible patients. Notably, patients in IMS-3 intervention arm who received no IV therapy due to various exclusion reasons did not show any functional benefit at 3 months despite good recanalization rates. This leads us to speculate whether the patients who showed functional improvement at 3 months in the present study were those who received IV thrombolysis within the window period as well? Moreover, the etiology of stroke is not clear in this study. Cardioembolic strokes are likely to recanalize earlier and have better functional outcomes eventually. It would also be prudent to know the proportion of patients who had excellent recovery at 24 hours (NIHSS improvement >9 points or 0) and whether any of the patients required decompressive craniotomy following a complete recanalization. The younger mean age of patients in the present study might also mean that risk factors other than the traditional atherosclerotic risk factors may be responsible for stroke in these patients. Moreover, as pointed out by the authors, younger patients tend to have better recovery after stroke. [3] Time to reperfusion is a major determinant of outcomes and it would be interesting to know whether the time to recanalization influenced outcomes and hemorrhage rates. [4]

In spite of the excellent outcome results seen in this study, we remain skeptical about the current status of endovascular therapy in an acute stroke setting and believe that it is still premature to consider primary endovascular therapy as efficacious in acute stroke. Until larger studies show a stronger correlation between recanalization rates and functional outcome, IV thrombolysis remains the gold standard for management of acute stroke.

References

1Huded V, Nair RR, deSouza R, Vyas DD. Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center. Neurol India 2014;62:276-9
2Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Interventional Management of Stroke (IMS) III Investigators. Interventional management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Eng J Med 2013;368:893-903.
3Singer OC, Haring HP, Trenkler J, Nolte CH, Bohner G, Reich A, et al. Age dependency of successful recanalization in anterior circulation stroke: The ENDOSTROKE study. Cerebrovasc Dis 2013;36:437-45.
4Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: A meta-analysis. Stroke 2007;38:967-73.