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Although there has been great hope that endovascular treatment would improve the outcome of patients with acute ischemic stroke, current data from completed randomized trials have failed to provide evidence that endovascular treatment is superior to medical treatment.1–3 These trials, however, have been criticized for poor patient selection, delay from stroke onset to initiation of endovascular treatment and limited success in achieving adequate revascularization of occluded intracranial arteries with the first-generation devices used in these trials.4 To establish that endovascular therapy is more effective than medical treatment in subgroups of patients with acute ischemic stroke in future trials, progress will need to be made on all three of these fronts.
Some progress has already been made in refining patient selection criteria and instituting programs to reduce the time from stroke onset to initiation of treatment,5 but the most remarkable progress has been made in improving revascularization with newer devices. In previous randomized trials with first-generation devices, the limited success in revascularization was attributed to one or more of the following: high rate of failure to achieve recanalization; long duration from groin puncture to revascularization; or inadequate restoration of sufficient antegrade flow. Two subsequent randomized trials (SWIFT6 and TREVO 27) evaluating newer devices, the stent retrievers, showed that these devices were significantly more effective for …
Competing interests The author has received the following grant support from NIH/NINDS for research related to the secondary prevention of stroke in patients with intracranial arterial stenosis: the WASID Trial (R01 NS36643), the NIH Wingspan Registry (R01 NS051688), the SAMMPRIS Trial (U01 NS058728) and a K24 grant (K24 NS050307). Corporate support for this research has consisted of Bayer providing aspirin and placebo aspirin for the WASID trial, Bristol-Myers Squibb supplying warfarin and placebo warfarin for the WASID trial, Stryker Neurovascular (formerly Boston Scientific Neurovascular) providing study devices and supplemental funding for third party device distribution, site monitoring and study auditing in the SAMMPRIS trial, and the Investigator-Sponsored Study Program of AstraZeneca that donated rosuvastatin (Crestor) to study patients in SAMMPRIS.
Provenance and peer review Commissioned; internally peer reviewed.