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March 2017

Mechanical Thrombectomy for Acute Ischemic Stroke: Are We Done?

Author Affiliations
  • 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo
  • 2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
JAMA Neurol. 2017;74(3):259. doi:10.1001/jamaneurol.2016.5322

Coutinho et al1 have performed a timely post hoc analysis consisting of a patient population from 2 large, prospective, core laboratory–adjudicated trials: Solitaire With the Intention for Thrombectomy (SWIFT) and Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), and their report appears in this issue of JAMA Neurology. Given that 85% of the patients in mechanical thrombectomy (MT) trials received intravenous thrombolysis (IVT), they highlight an important group of patients in whom MT was successful without IVT. The recent IVT and MT trials have clearly established the new standard in therapy for proximal anterior circulation occlusions.2-6 A key question that has arisen is whether there is any additional benefit to IVT in these patients undergoing MT. Although there are hypothetical benefits, such as increased recanalization and thrombolysis of smaller clot fragments, there are also hypothetical concerns regarding increased risk for intracranial hemorrhage and greater fragmentation with reduction in MT effectiveness for more complete recanalization, including Thrombolysis in Cerebral Infarction 3 flow. A few studies,7,8 both prospective and retrospective, have attempted to introduce this question but are significantly limited by design issues, sample size, and other methodologic considerations. Although we believe that this is an ideal question for a prospective randomized clinical trial, the current study provides the largest independent core laboratory with a clinical end point committee– or a data and safety monitoring board–adjudicated prospective, multicenter data set that highlights the question and provides critical data that can be used to design a definitive randomized clinical trial. We concur with the authors in their discussion of limitations that this data set should be interpreted with caution in regard to increased risk for symptomatic intracranial hemorrhage in the IVT arm as well as imbalances, such as with atrial fibrillation, the Alberta Stroke Program Early CT Score, and procedural vasospasm.

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