A groundbreaking scientific advisory from the American Heart Association (AHA) has synthesized data from six randomized controlled trials, revealing compelling evidence for the efficacy of endovascular therapy (EVT) in treating large-core ischemic strokes. The findings, published in the journal Stroke, mark a significant shift in understanding the role of reperfusion therapies for this challenging patient population.
Clinical Trial Findings and Impact
The comprehensive analysis encompassed six major trials - ANGEL-ASPECT, LASTE, RESCUE-Japan LIMIT, SELECT2, TENSION, and TESLA - collectively involving 1,887 patients across multiple countries including Australia, Canada, China, Japan, New Zealand, the USA, and several European nations. The trials demonstrated that EVT, when combined with standard medical management, yielded superior outcomes compared to medical management alone.
Dr. Nestor Gonzalez, chair of the scientific advisory committee at Cedars-Sinai Medical Center, emphasized the paradigm shift: "The [previous] idea was that, maybe, patients that have very large-core strokes would not benefit from endovascular interventions. In the last two years, six clinical trials have changed our perspective."
Key Outcome Measures
The data revealed striking improvements in patient outcomes:
- Functional independence at 90 days: 19.5% in EVT group vs 7.9% in medical management group
- Independent ambulation: 36% with EVT vs 19% with medical management
- Number needed to treat: 8 patients to prevent one case of functional dependence
Safety Profile and Complications
The safety analysis showed encouraging results:
- Symptomatic hemorrhages varied between trials but showed no statistically significant differences between treatment groups
- Decompressive craniectomy rates remained comparable between EVT and medical management
- Most trials indicated favorable 90-day mortality rates with EVT
Study Limitations and Future Directions
The advisory committee identified several important limitations:
- Predominant enrollment of younger stroke patients
- Limited inclusion of individuals over 85 years
- Focus on patients with minimal pre-stroke disability (modified Rankin scale 0-1)
- Varying time windows from stroke onset
- Different degrees of infarction (ASPECTS scores)
Clinical Implications
The advisory supports EVT use in patients meeting specific criteria:
- Good pre-stroke functional status (mRS 0-1)
- Substantial stroke severity (NIHSS score ≥6)
- Internal carotid or proximal middle cerebral artery occlusion
- Large ischemic core (ASPECTS 3-5) on initial imaging
Dr. Gonzalez noted that while the improvements in functional independence are significant, they remain modest: "Roughly, only 20% of the patients reached that level. There was a little bit of a bigger impact on the ability of these patients to walk but, still, patients with large-core stroke have significant morbidity that needs to be considered."
Future Research Priorities
The advisory highlights several areas requiring further investigation:
- Patient outcomes in different imaging protocols
- Treatment efficacy in very large ischemic cores (ASPECTS 0-2)
- Results in patients presenting beyond six hours from symptom onset
- Quality of life assessments
- Cost-effectiveness analyses
- Role of advanced imaging in patient selection
