It's about time: Stroke care

By Alan H. Matsumoto, MD, FSIR, FACR, FAHA

SIR 2015–16 President

What a difference evidence-based medicine and time make—especially for a patient with an acute ischemic stroke.

Nearly 800,000 individuals in the United States suffer a stroke each year. The time from the onset of symptoms to treatment remains crucial in stroke patients.  You’ve heard the phrase, “time is brain.” For every minute a stroke is untreated, a patient loses 1.9 million brain cells and 14 billion connections between brain cells.

What has been the role of interventional radiology in stroke treatment? Interventional radiologists (IRs) have been involved in the delivery of endovascular stroke care since its inception and remain among the most involved specialists in the delivery of catheter-based therapies in many hospitals across the nation. While many stroke centers worldwide have performed endovascular stroke therapy since the 1990s, uncertainties have remained about its efficacy and which patients are most likely to benefit. Some previous studies suggested that endovascular therapy may be no more effective than intravenous tissue plasminogen activator (t-PA) alone.

However, multiple recent randomized clinical trials have shown that endovascular therapy with mechanical thrombectomy is highly beneficial, as compared to intravenous tPA alone or more conservative therapies, in select patients with acute ischemic stroke and moderate to severe neurological deficits due to a proximal cerebral artery occlusion. These quality outcomes-based findings—along with improved patient selection criteria, refined imaging and device technology and a heightened awareness of the importance of time—have demonstrated improved outcomes for stroke patients. (1-4)

What do these recent stroke studies mean to interventional radiologists? These endovascular stroke trials provide a prime opportunity for IRs to further engage in and apply the very best of image-guided therapies.  The beneficial results of these trials have major implications for stroke care systems, which is prompting a wide-scale and rapid move to add endovascular therapy to the infrastructure of stroke service lines.

Having the clinical acumen, knowledge of cerebrovascular anatomy, diagnostic imaging expertise and advanced catheter-based technical skills, SIR members can help to fill the void and provide the necessary high-quality physician services to address this medical practice need.  In collaboration with a multidisciplinary team focused on stroke care, IRs can become an even greater and more integral component of this service line and have a profound and positive impact on patients who present with a potentially devastating acute ischemic stroke due to a large cerebral artery occlusion.

Therefore, I challenge IRs to continue to be involved in and/or expand their service involvement in this arena to help health care systems deliver on the promise of these current stroke thrombectomy trials. In the end, we want stroke patients to benefit, and IRs can have a significant part in their outcome.

How is SIR supporting members? With our “vision to heal,” we plan to drive the future of our specialty by supporting you. We are championing the importance that IRs hold in today’s medical practice, demonstrating how you are helping to improve outcomes by offering new treatment options for patients. Because of the findings from these recent trials—along with urgent recommendations voiced by members of our Interventional Neuroradiology Service Line—SIR will be providing you new learning opportunities in stroke care to address ongoing educational needs, while also increasing our collaboration with other specialties.

SIR is developing a course, targeted to IRs with cerebral angiography experience who are currently performing or interested in providing endovascular acute stroke therapy as a member of a multidisciplinary stroke team. The one-day course, which will be held at SIR 2016 in Vancouver, will cover establishing an acute stroke system of care, severity assessment,  imaging and patient selection criteria for endovascular therapy,  current endovascular devices and technical considerations for using catheter-based acute stroke therapies and hands-on instruction on the use of current thrombectomy devices.

SIR will also continue to ensure excellence in practice by developing clinical practice guidelines and tracking outcomes data to provide the necessary support for expanding use of interventional radiology services. In addition to training, we will be reviewing and revising the multi-society quality improvement guidelines for stroke.

For stroke patients and for members … it’s about time.

References 

1. Berkhemer OA, et al. MR CLEAN Investigators. A randomized trial of intra-arterial treatment for acute ischemic stroke. 
2. NEJM 2015; 372: 11-20. Goyal M et al. ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. 
3. NEJM 2015: 372: 1019-30. Campbell BC et al. EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. 
4. NEJM 2015; 372: 1009-18. Saver JL et al.  SWIFT PRIME Investigators. Stent-retriever thrombecctomy after intravenous t-PA vs. t-PA alone in stroke. NEJM,April 17, 2015. epub ahead of print.