Lots of statistics to make sure laypersons can't use this and ask intelligent question of their doctors. Again with the cherry picking of patients. NO stroke survivor should be left behind.
Impact of the Thrombectomy Trials on the Management and Outcome of Large Vessel Stroke: Data From the Lyon Stroke Center
- 1Department of Neuroradiology, Université Lyon 1, Hospices Civils de Lyon, Lyon, France
- 2Health Information Department, HESPER EA7425, Université Lyon 1, Hospices Civils de Lyon, Lyon, France
- 3Department of Stroke Medicine, Université Lyon 1, Hospices Civils de Lyon, Lyon, France
- 4CREATIS, CNRS UMR 5220-INSERM U1206, INSA-Lyon, Hospices Civils de Lyon, Lyon, France
Introduction: Randomized trials (RT)
have recently validated the superiority of thrombectomy over standard
medical care, including intravenous thrombolysis (IVT). However, data on
their impact on routine clinical care remains scarce.
Methods: Using a prospective
observational registry, we assessed: (1) the clinical and radiological
characteristics of all consecutive patients treated with thrombectomy;
(2) the outcome of all patients with M1 occlusion (treated with
thrombectomy or IVT alone). Two periods were compared: before
(2013–2014) and after (2015–2016) the publication of RT.
Results: Endovascular procedures significantly increased between the two periods (N = 82 vs. 314, p < 0.0001). In 2015–2016, patients were older (median [IQR]: 69 [57-80]; vs. 66 [53-74]; p = 0.008), had shorter door-to-clot times (69 [47-95]; vs. 110 [83-155]; p < 0.0001) resulting in a trend toward shorter delay from symptom onset to reperfusion (232 [185-300]; vs. 250 [200-339]; p = 0.1), with higher rates of reperfusion (71 vs. 48%; p
= 0.0001). Conversely, no significant differences in baseline NIHSS
scores, ASPECTS, delay to IVT or intracranial hemorrhage were found. In
2015–2016, patients with M1 occlusion were treated with thrombectomy
more often than in 2013–2014 (87 vs. 32%, respectively; p <
0.0001), with a significant improvement in clinical outcome (shift
analysis, lower modified Rankin scale scores: OR = 1.68; 95% CI:
1.10–2.57; p = 0.017).
Conclusion: Following the publication of
RT, thrombectomy was rapidly implemented with significant improvements
in intrahospital delay and reperfusion rates. Treatment with
thrombectomy increased with better clinical outcomes in patients with M1
occlusion.
Introduction
In 2013, the future of endovascular therapy (EVT) in
acute ischemic stroke was uncertain, as three consecutive randomized
trials failed to demonstrate the superiority of thrombectomy combined
with intravenous thrombolysis (IVT) over IVT alone (1–3).
Subsequent trials have since established the effectiveness of EVT for
patients with large vessel occlusions who were suitably selected by
cerebral and arterial imaging (4–11).
Preliminary reports from monocentric (12, 13) or multicentric (14, 15)
studies indicate that EVT seems applicable in the “real” world of
clinical practice, with similar results to those of controlled trials.
Still, little data is available on how systems of care have started to
adapt to this paradigm shift in acute stroke therapy. A single study
recently reported on the increasing EVT case volumes across the Unites
States since the publication of the positive trials (16).
The extent to which EVT use has evolved after the pivotal trials and
its impact on local practices need to be considered to plan further
quality improvement efforts, both within comprehensive stroke centers
(CSC, i.e., EVT-capable hospitals) and beyond.
Our institution is the only CSC serving the greater Lyon
metropolitan area (population: 2.3 million), treating ~1,600 ischemic
stroke patients each year (Figure 1). Prior to the publication of the first positive trial (4),
EVT was not considered as standard care, and thus was not
systematically considered for patients with proximal intracranial
occlusions. Thereafter, local processes were modified to implement
thrombectomy in all eligible patients referred to our CSC. Our objective
was to assess the effects of this major shift in our reperfusion
strategy by comparing two periods: before (January 1st 2013–December
31st 2014) and after (January 1st 2015–December 31st 2016) the
publication of the first positive EVT trial. Specifically, we first
compared the typology of all consecutive EVT cases (e.g., number of
procedures, baseline clinical and radiological characteristics) to
assess the development of EVT within our institution. Secondly, we
compared the outcome of all patients with M1 occlusion who underwent a
revascularization procedure (IVT and/or EVT).
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