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Red pill, blue pill: reflections on the emerging large vessel stroke ‘market’
  1. Ansaar T Rai
  1. Correspondence to Dr Ansaar T Rai, Department of Interventional Neuroradiology, West Virginia University Hospital, Morgantown, WV 26508, USA; ansaar.rai{at}

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In an iconic scene in ‘The Matrix’, Morpheus gives Neo the choice of taking either the blue pill or the red pill. The blue pill to keep him in his current blissful, fantastical world of illusion and the red pill to shatter that fantasy jolting him into the ‘real world’. The current hype about the potentially explosive growth of endovascular stroke therapy is a blue pill. Neo of course takes the red pill and wakes up to the realities of his time, but will we?

Don't get me wrong, I firmly believe that the recent trials will do for acute ischemic stroke what the International Subarachnoid Aneurysm Trial did for aneurysms. Over a few months we reached milestones that were thought to be many years away, if not unreachable. Suddenly, what we did as neurointerventionalists made sense and was supported by data—not data open to interpretation, but unstinted evidence that appropriately triaged patients will benefit from endovascular revascularization. These trials were the result of a focused, shared objective and collaboration between physicians, industry, and government agencies to assess the cohort of patients best suited for endovascular therapy— that is, those with large vessel strokes.

Working at a center that participated in these and previous studies, I am well aware of the resource-intensive and logistically challenging nature of interventional ischemic stroke trials. About 3 years ago, after much soul searching and review of the evidence, our institution decided to offer endovascular therapy only to patients in a clinical trial. We did this despite our personal convictions and criticisms of the negative endovascular studies because we might be wrong—and if wrong, then doing everything right to discover the truth. Thus all eligible, consecutive patients were enrolled without bias in a trial and we experienced the agony of randomizing relatively young patients with middle …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.