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A research roadmap of future endovascular stroke trials
  1. Rishi Gupta1,
  2. Ansaar T Rai2,
  3. Joshua A Hirsch3,
  4. Italo Linfante4,
  5. William Mack5,
  6. J Mocco6,
  7. Felipe Albuquerque7,
  8. Michael Chen8,
  9. David Fiorella9,
  10. Robert W Tarr10
  1. 1Department of Neurosurgery, Wellstar Medical Group, Marietta, GA, USA
  2. 2Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
  3. 3NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
  4. 4NeuroEndovascular Program, Baptist Cardiac and Vascular Institute, Miami, Florida, USA
  5. 5Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
  6. 6Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
  7. 7Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  8. 88Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
  9. 9Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook, New York, USA
  10. 10Department of Radiology, University Hospitals Case Medical Center, Cleveland, OH, USA
  1. Correspondence to Dr Rishi Gupta, Wellstar Medical Group, Neurosurgery 61 Whitcher Street, Suite 3110 Marietta, GA 30060 rishi.gupta{at}

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The recent completion of the MR CLEAN trial1 and news of early stoppage of other stroke trials demonstrates the ability for the neurointerventional community to address a crucial question that has hindered the ability of intra-arterial therapy (IAT) to be offered more widely. The focus of future studies will now shift towards improving clinical outcomes in patients undergoing IAT.

Patient selection


There is currently no consensus regarding the optimal imaging strategy for the selection of patients for intervention. The modality must be efficient, accurate, available and repeatable. Non-contrast CT using Alberta Stroke Program Early CT Score (ASPECTS) scoring,2 CT perfusion and MRI are all in widespread clinical usage at interventional stroke centers. A trial comparing different modes of imaging based patient selection would be valuable and currently does not exist. There are advantages and disadvantages to each technique with strong beliefs that each modality has its advantages.

The question is whether the widespread availability, ease of access and time savings justify using non-contrast CT (supplemented by ASPECTS) as ‘good enough’ to select patients when compared to advanced imaging modalities that may be more specific to detecting ischemia. Developing an educational pathway with ASPECTS scoring to reduce inter-rater variability along with a standardized CT perfusion algorithm that can be replicated across institutions can allow for a trial examining this question to occur. The current landscape would potentially also allow for an MRI comparative trial.

One starting point might be a core-lab adjudicated, prospective registry comparing pre- and post-treatment ASPECTS, computed tomography perfusion (CTP) and/or MRI data from …

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  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.