Mechanical Devices for Acute Stroke Intervention: Why Did the Trials Fail?

12th Biennial Meeting of the International Andreas Gruentzig Society:  Rio de Janeiro - February 2-6, 2014

From Session 7 — Endovascular

Moderator:     Dieter Liermann
Panelists:      Robert Bersin, Tyrone Collins, Gyula Gal, Klaus Mathias, Sigrid Nikol, Souheil Saddekni, Jiri Vitek

Framing the question at hand, what is the state of the current knowledge?

We have a high number of trials but only a small number of interventional treatments. The review of randomized trials of intra-cranial intervention in stroke show two randomized trials which failed. This might be caused by poor trial design, slow enrollment, and insufficient experience of the operator chosen.

In general, the analysis for the failure of trials concerning mechanical devices for acute stroke interventions have a big variety of potential reasons. One problem seems to be the poor and old, less effective devices available at this time for acute stoke interventions. Additional problems might be caused in the selection of patients and the availability of the operator. Logistical issues are of importance. Competition seems to be a major reason for why intra-arterial therapy for stroke is so rarely used.

What are the Gaps in the Current Knowledge?

We have to find out if endovascular therapy is superior to non-endovascular therapy. Trials were poorly executed which take a long time from randomization to treatment.
The education and the behavior of patients is an important precondition for the effectiveness of the therapy in case of an acute stroke, as well as the manpower and the specialists available for the therapy. We have to rule out which patient to treat, which device to use and how are the results and the effectiveness of newer devices as well as the important question who should perform the intervention. It is important to know which of the acute stroke patients benefit from thrombectomy and intraarterial lysis using new devices.

Our Summary and Recommendations

New properly designed randomized trials with new effective devices for primary mechanical approach, high volume established stroke intervention centers, better education of patients and physicians, well developed infrastructures, salvation of logistical issues as well as the need of neurologists and neurosurgeons in diagnosis and therapy are needed to help us provide a clear recommendation for the use of mechanical devices for acute stroke interventions.