http://journal.frontiersin.org/article/10.3389/fneur.2015.00117/full?
- 1Department of Neuro Interventional Surgery, Akron General Medical Center, Akron, OH, USA
- 2Department of Research, Akron General Medical Center, Akron, OH, USA
Introduction
The interventional management of stroke (IMS) III trial (1)
showed non-superiority of intra-arterial (IA) revascularization
combined with intra venous (IV) tissue plasminogen activator (tPA)
treatment over IV tPA alone, and the systemic thrombolysis for acute
ischemic stroke (SYNTHESIS) trial demonstrated similar lack of favorable
clinical outcomes for IA versus IV tPA therapy (2).
This is despite the high revascularization rate in the IA arms in these
trials. The role of intra-arterial treatment for acute ischemic stroke
(IAT-AIS) has been contested. Paradoxically, however, the benefit of
revascularization to clinical outcomes is convincingly attested to in
prior literature. In a recent meta-analysis of 998 patients with
clinical follow-up at 3 months, good clinical outcome was found in 58%
of revascularized patients as compared to 24.8% in non-revascularized
patients (3).
When revascularization occurred within the first 6 h, good clinical
outcomes (GCOs) were found in 50.9% of revascularized patients as
compared to 11.1% in non-revascularized patients. Other authors reached
similar conclusions. Even in the IMS III trial, better revascularization
using the modified thrombolysis in cerebral infarction (mTICI) score
led to better outcomes than those for patients who achieved lesser
revascularization (1).
This data were recently resolved with the publication of newer trials.
In MR CLEAN, EXTEND-IA, and ESCAPE, good recanalization rates were
achieved in 58.7, 86, and 72.4% of patients, respectively, with
accompanying GCO rates at 32.6, 71, and 53%, respectively (4–6).
While these results demonstrate IA superiority with higher
recanalization rates than with IVT, there are still a significant number
of patients who achieved good and timely revascularization that did not
also achieve GCOs. So if better revascularization improves outcome and
IA treatment has a better revascularization rate than IV treatment, how
can we explain the lack of GCOs in some of these patients?
Revascularization and Outcome
Revascularization is defined as the restoration of
anterograde blood flow to the ischemic area through the recently
occluded artery. Currently, this is reported using the mTICI score, with
mTICI of 2b or 3 being considered successful revascularization (7).
The aim of revascularization is to produce clinical improvement through
restoring the cerebral blood flow (CBF) level to greater than the
critical threshold of 23 ml/100 g/min of viable brain tissue (8). This should translate into a permanent resolution of AIS symptoms by saving the ischemic tissue before it progresses to irreversible damage. So if perfect revascularization is achieved (mTICI = 3) in a timely
manner, i.e., before ischemia becomes irreversible, clinical
improvement should be achieved for almost all patients, as well as for
the majority of patients with less effective revascularization (mTICI =
2b). However, review of the literature reveals that only around 50% of
patients in whom we obtained timely recanalization (mTICI 2b, 3) will
achieve a good clinical outcome (Table 1) (1, 2, 9–13).
Attempting to solve the paradox regarding why all technically
successful revascularizations do not translate into GCOs should help us
improve our revascularization strategy.
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