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Systematic regionalization of stroke care
  1. Kyle M Fargen1,
  2. David Fiorella2,
  3. Felipe Albuquerque3,
  4. J Mocco4
  1. 1Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  2. 2Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook, New York, USA
  3. 3Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  4. 4Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA

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Introduction

In January, the Multicenter Randomized CLinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN) trial, demonstrated an unambiguous benefit of intra-arterial therapies (IATs) for the treatment of patients with emergent large vessel occlusion (ELVO).1 The results of MR CLEAN were reinforced by the early cessation of EXTEND-IA and ESCAPE. These two additional randomized controlled trials (yet to be published) showed similarly improved outcomes in patients receiving IAT rather than medical management (Goyal M, Campbell B, personal communication). Furthermore, a meta-analysis including all six prospective, randomized controlled trials published to date comparing IAT with standard medical care in patients with ELVO confirmed better outcomes in those undergoing IAT.2 The overwhelming evidence provided by these recently completed studies has eliminated clinical equipoise between IAT and medical therapy for a large number of patients.3

Nonetheless, much remains to be done. While MR CLEAN supports better outcomes in patients undergoing IAT, the collective data on stroke outcomes remain sobering. Despite early presentation, treatment with intravenous tissue plasminogen activator (IV tPA), and subsequently IAT …

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