Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
J Stroke. 2015 May;17(2):123-6. doi: 10.5853/jos.2015.17.2.123. Epub 2015 May 29.
The treatment of acute ischemic stroke (AIS) in the setting of intracranial large artery occlusion (LAO) with intravenous tissue plasminogen activator (IV-tPA) is associated with low rates of recanalization and high rates of neurological morbidity and functional dependence. Endovascular intervention, particularly mechanical thrombectomy, is a promising therapeutic adjunct to IV-tPA for the treatment of acute LAO. However, until recently, its efficacy has been controversial. In this brief review, we analyze the criticisms of three negative randomized controlled trials (RCT) of endovascular stroke treatment and evaluate the results from seven positive endovascular stroke RCTs that have recently been presented or published. IMS III, MR RESCUE, and SYTHESIS Expansion were three RCTs that failed to show a benefit from endovascular stroke therapy. Major criticisms of these studies included a lack of routine screening for LAO, resulting in the selection of AIS patients without LAO for endovascular intervention, and a low utilization rate of modern endovascular thrombectomy devices, leading to substandard rates of successful recanalization. MR CLEAN was the first phase III RCT to show a significant clinical benefit from endovascular stroke therapy. The dissemination of its findings elicited a cascade of positive results from, to date, six additional endovascular stroke RCTs, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, THERAPY, and THRACE, which were halted prematurely for efficacy. The cumulative evidence from these studies shows an overwhelming benefit from the endovascular treatment of acute LAO, therefore effectively establishing a new standard of care for the management of AIS.
在颅内大动脉闭塞（LAO）的情况下，静脉注射组织型纤溶酶原激活剂（IV-tPA）治疗急性缺血性脑卒中（AIS），其再通率较低，神经功能残疾和功能依赖性发生率较高。血管内介入治疗，特别是机械血栓切除术，是 IV-tPA 治疗急性 LAO 的一种有前途的辅助治疗方法。然而，直到最近，其疗效一直存在争议。在这篇简短的综述中，我们分析了对三项血管内卒中治疗的阴性随机对照试验（RCT）的批评，并评估了最近提出或发表的七项阳性血管内卒中 RCT 的结果。IMS III、MR RESCUE 和 SYTHESIS Expansion 是三项未能显示血管内卒中治疗获益的 RCT。这些研究的主要批评包括缺乏对 LAO 的常规筛查，导致选择没有 LAO 的 AIS 患者进行血管内介入治疗，以及现代血管内血栓切除术设备的利用率低，导致再通成功率不达标。MR CLEAN 是第一项表明血管内卒中治疗具有显著临床获益的 III 期 RCT。其研究结果的传播引发了迄今为止另外六项血管内卒中 RCT 的积极结果，包括 ESCAPE、EXTEND-IA、SWIFT PRIME、REVASCAT、THERAPY 和 THRACE，这些 RCT 因疗效而提前终止。这些研究的累积证据表明，急性 LAO 的血管内治疗具有压倒性的获益，因此有效地为 AIS 的治疗建立了新的护理标准。
