Abstract:

The effectiveness and safety of endovascular thrombectomy for the treatment of large vessel occlusion (LVO) have been demonstrated in landmark randomized controlled trials. However, patients in these studies were pre-selected and recruited using stringent inclusion and exclusion criteria. The STRATIS registry has evaluated almost 1,000 US patients, with acute stroke, who received endovascular thrombectomy treatment for LVO with a Medtronic stent retriever device in a less stringent “real word” hospital setting. STRATIS data demonstrate that the outcomes and level of safety achieved in RCTs can also be achieved in a non-selective cohort of acute stroke patients, with higher mean baseline NIHSS scores, and with more risk factors than patients in the SEER collaboration database. Patients in STRATIS who were routed directly to a comprehensive stroke centre, compared with patients who were transferred from a peripheral community hospital, to an endovascular centre, had better clinical outcomes and a shorter onset to puncture time.

Two randomized controlled trials are in progress to address the questions of whether acute stroke patients with LVO should by pass local community hospitals in favour of direct transfer to a comprehensive stroke centre, and whether direct mechanical thrombectomy is non-inferior to IV t-PA plus mechanical thrombectomy. The ongoing RACECAT trial has been designed to compare the TRAnsfer to the Closest local stroke centre vs. direct transfer to Endovascular stroke Centre of Acute stroke patients with suspected large vessel occlusion in the Catalan Territory. This study will provide specific randomized data that will help decide which transportation option provides the best outcome for acute stroke patients.

The SWIFT Direct study is: Solitaire™ With the Intention For Thrombectomy plus intravenous t-PA versus DIRECT Solitaire^TM stent-retriever thrombectomy in acute anterior circulation stroke. The focus of this trial is to determine whether subjects, in Canada and Europe, with an acute ischaemic stroke in the anterior circulation, who are referred to a stroke centre with endovascular facilities, and who are candidates for IV t-PA , will have a non-inferior functional outcome at 90 days when treated with direct mechanical thrombectomy, compared with subjects treated with combined IV t-PA and mechanical thrombectomy.

SIM & SIZE^TM is a new simulation software that helps interventional neurologists to optimize and validate their choice of endovascular flow diverter devices for the treatment of intracranial aneurysms. Clinical benefits associated with this software include the successful deployment of shorter devices, and the need for significantly less secondary implants per procedure.

Acknowledgements: The editorial assistance of Mr Rob Goodwin, Oruen Ltd, in the preparation of this article is acknowledged with thanks.

Keywords:

STRATIS, RACECAT, SWIFT Direct, acute stroke, large vessel occlusion, endovascular thrombectomy, SIM & SIZE, simulation software.