Progress with stroke
The recent stroke conference highlighted a score of advancements, proof of the commitment and creativity devoted to this complex condition.
Findings of benefit from endovascular treatments in some of the late-breaking clinical trials may have been expected, based on the early termination of the studies. The EXTEND-IA (Extending the Time for Thrombolysis in Emergency Neurological Deficits — Intra-Arterial (EXTEND-IA) trial stopped enrollment at 70 patients after a midterm analysis showed efficacy. A review of the ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times) data also found efficacy, which prompted its termination.
This contrasts with some other conference presentations in the past 12 months, where futility more frequently was the call. Beyond that, slower-than-expected enrollments, loss to follow-up and other impediments have made conducting these randomized, controlled trials challenging. The results have been ambiguous, underpowered and overall a disappointment—probably no more so than to the researchers and patients involved in the studies.
The American Stroke Association’s (ASA) 2015 international Stroke Conference in Nashville, Tenn., kicked off on a high note. EXTEND-IA tested a strategy that combined advanced imaging, current technology and early treatment in patients with ischemic stroke against standard care. The 70 patients enrolled first received alteplase and then were randomized to endovascular therapy with a retrievable stent or continued alteplase therapy. Results on reperfusion at 24 hours, early neurological improvement at three days and improved functional outcomes all favored the endovascular approach.
ESCAPE randomized 316 patients to standard care or standard care plus rapid endovascular treatment with thrombectomy devices. The endovascular intervention won on functionality, mortality and quality of life symptomatic but intracerebral hemorrhage rates were higher in the endovascular group.
The late-breakers bring a wow factor, based on the quality of the research and the likelihood that the results will change practice. Oral abstracts, symposia and other presentations also deserve attention, though, for providing insights and pathways for better care.
And it need not mean expensive new technologies. For instance, a study on dehydration in patients presenting with stroke found worse outcomes in dehydrated vs. hydrated patients. This is a preliminary finding, but one that might inform a future randomized trial to look at rehydration as a simple and inexpensive intervention. Correcting for vitamin D deficiency may offer another low-cost avenue to reduce stroke risk.
Stroke comes in fourth place as a cause of death in the U.S., according to ASA, and first place as the cause of disability. As the neurologists and other physicians at this year’s stroke conference have shown, many stroke risks are modifiable and many disabilities are preventable. That should make a dent in the statistics—and more importantly, a difference in patients’ lives.
Candace Stuart
Editor, Cardiovascular Business