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Editor's Note
July 16, 2019

Endovascular Therapy for Acute Ischemic Stroke Treated in Clinical Practice

Author Affiliations
  • 1JAMA, Chicago, Illinois
  • 2Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
JAMA. 2019;322(3):263. doi:10.1001/jama.2019.8289

Five randomized clinical trials, published in 2015, demonstrated the benefit of endovascular therapy in appropriately selected patients with acute ischemic stroke due to large vessel occlusion, and a subsequent individual patient data meta-analysis of these trials indicated that the benefit associated with endovascular therapy was greater the earlier that endovascular reperfusion was achieved.1 Since publication of these important trials, the use of endovascular therapy in the United States has significantly increased,2 and efforts are ongoing to maximize the potential benefits of endovascular therapy for the greatest number of eligible patients possible.

This issue of JAMA includes a report from a US nationwide clinical registry—the Get With The Guidelines-Stroke registry—which describes the clinical, technical, and adverse event outcomes in 6756 patients with acute ischemic stroke who underwent endovascular reperfusion therapy in 2015 or 2016 within 8 hours of symptom onset, the generally accepted time window for thrombectomy during the study period.3 Given the increasing use of endovascular therapy and the highly selected patient population included in the prior randomized clinical trials, evaluation of outcomes in a large group of patients in routine clinical practice is important.

The study findings generally confirmed the time-benefit relationship previously established in clinical trials, showing that shorter time to endovascular reperfusion therapy was associated with better outcomes and demonstrating generalizability outside of a clinical trial setting. The data may also be useful because they quantify contemporary time-to-treatment estimates for US stroke systems of care and may help inform potential future treatment target times for endovascular therapy.

The findings also suggest the possibility of a nonlinear time-outcome relationship, with more rapid loss of benefit in the first few hours after stroke onset. As indications for endovascular therapy continue to evolve (eg, with the use of perfusion imaging for patient selection), these data may help guide the use of advanced imaging for determining patients’ candidacy for endovascular intervention. Future studies will need to consider broader time windows as the use of endovascular therapy expands beyond the time window evaluated in this study.

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Article Information

Corresponding Author: Christopher C. Muth, MD, JAMA, 330 N Wabash Ave, Chicago, IL 60611 (christopher.muth@jamanetwork.org).

Conflict of Interest Disclosures: None reported.

References
1.
Saver  JL, Goyal  M, van der Lugt  A,  et al; HERMES Collaborators.  Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis.  JAMA. 2016;316(12):1279-1288. doi:10.1001/jama.2016.13647PubMedGoogle ScholarCrossref
2.
Smith  EE, Saver  JL, Cox  M,  et al.  Increase in endovascular therapy in Get With the Guidelines-Stroke after the publication of pivotal trials.  Circulation. 2017;136(24):2303-2310.PubMedGoogle Scholar
3.
Jahan  R, Saver  JL, Schwamm  LH,  et al.  Association between time to treatment with endovascular reperfusion therapy and outcomes in patients with acute ischemic stroke treated in clinical practice.  JAMA. doi:10.1001/jama.2019.8286Google Scholar
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