Acute Stroke Intervention: Where Do We Stand?


Speaker:              Nick Hopkins

Moderator:              Richard Gray

Panelists:              Barry Katzen, Jiri Vitek      


What is available for acute stroke patient beyond thrombolysis?
There are many gaps in the relatively new field of neuro-intervention, including an understanding of the physiology of the infarct penumbra for acute stroke, the device technology, knowledge about which patients benefit from interventional treatment and manpower needs.
The field of acute stroke treatment remains about 10 years behind that of acute myocardial infarction. It is from that experience that the field of stroke care is learning.  Like cardiology, we started with thrombolytic therapy, then moved to clot retrieval devices and then went to stents. CT perfusion has revolutionized the understanding of the role of revascularization. If you have signs of viable brain on perfusion imaging then it is not all about time, but more about physiology.  In the hands of skilled operators and a seasoned team, examples of outstanding clinical results can be achieved, with as many as 45% of victims showing near a normal outcome. With even more rapid diagnosis and with hypothermia, we should be able to expect even better results. With the exception of hypothermia, studies of neuroprotective agents have been uniformly disappointing. This underscores the need for effective and safe interventional therapies. The recent SARIS clinical trial of revascularization in acute stroke is a disappointment but by no means should be taken as a test of the role of acute stroke intervention. However, it does point out the importance of the steep learning curve for operators and the need for more refined patient selection. We have to realize the sobering facts that not only is stroke a devastating illness, but our current therapies can have a real threat of harm, too.

Dr Hopkins described the concept and development of an interdisciplinary vascular Institute in upstate New York that epitomizes the value of regular and frequent interaction of various specialties, maximizes technology advances and has created effective systems of care for stroke and other victims of vascular diseases.

We need to understand the limits of viability in the stroke penumbra, seek support for appropriately designed clinical trials with realistic scientific aims. There needs to be a realistic appraisal of manpower available now and in the future as the indications and subsequent volume of patients become known. The opportunities for improving stroke therapy are great, but further technology and studies will be necessary to fill the knowledge gaps.