Stroke Research Continues to Support Rapid Assessment, Personalized Treatment Approaches

Some of the biggest stories in stroke care this year came fashionably late. Positive endovascular findings were seen in the Phase III MR CLEAN and ESCAPE trials, and the Phase II EXTEND-IA. “We are anxiously awaiting the manuscripts,” said Pooja Khatri, MD, Director of Acute Stroke for the University of Cincinnati Stroke Team, and Professor of Neurology and Rehabilitation Medicine at the University of Cincinnati.

Researchers heard the presentation of MR CLEAN at the World Stroke Congress in October, and can look forward to the manuscript in the New England Journal of Medicine in December; presentations of the ESCAPE and EXTEND-IA trials are slated in the upcoming months.

The MR CLEAN study was the first recent study with modern techniques to show a benefit for catheter-based treatments for acute stroke patients. “This data confirms our practice of rapidly evaluating and treating the severe stroke patients with techniques to remove the thrombus from the blood vessel, and should allow advances in development of systems of care around these most severe of strokes,” said M. Shazam Hussain, MD, Stroke Section Head in the Cerebrovascular Center at Cleveland Clinic.

“It’s exciting to think that we may have our first proven acute ischemic stroke therapies since IV rt-PA, about 20 years ago,” Dr. Khatri said.

“It’s been a very exciting year,” Dr. Hussain said. “We’ve seen some important new guidelines, including the first stroke guidelines specific for women—these should provide a good standard and improve our care for women with or at risk for stroke. New guidelines for primary prevention of stroke have also just been released.”

He also stressed the launch of the mobile stroke treatment unit as a great advance for stroke care. The unit, equipped with a CT scanner on board as well as lab testing and telemedicine video conferencing, allows physicians to bring the ED to the patient and treat stroke patients in the field, saving precious time. Both the Cleveland Clinic and Houston’s mobile stroke treatment units were launched in 2014. “These should be the blueprint for many other centers across the country.”

Dr. Hussain said an overlooked story in 2014 was the release of data showing that for complex cerebrovascular disease, centers that treat a lot of patients have better outcomes. “This is true of both complex stroke as well as aneurysms,” he said. “I think we need to be mindful of this, especially as we continue to develop systems of care around the country.”

Dr. Khatri pointed to two major studies, EMBRACE and CRYSTAL AF, both published in the New England Journal of Medicine, that demonstrated higher rates of atrial fibrillation detection using 30-day cardiac monitors in cryptogenic ischemic strokes. “Evidence of improving long-term clinical outcomes by treating these patients with brief runs of atrial fibrillation with anticoagulation is lacking. However, these studies suggest that more diagnostic testing for atrial fibrillation should be considered,” she said.

“Additionally, the DESTINY 2 trial of hemicraniectomy in 80+ year olds suggested that, as with younger patients, they too may benefit from this intervention due to less death and severe disability—although significant disability remained frequent. Individualized decisions without strict age cutoffs should be considered in light of these new data.”

Looking ahead, Dr. Hussain is eager to see, hopefully completed in 2015, the first stem cell therapy trials. “And we hope there will be new treatment options for long term recovery for stroke. These, in addition to continued trials for catheter based stroke intervention and the mobile stroke unit should make 2015 a very exciting year.”

Dr. Khatri said a major overhaul of acute stroke care delivery will be needed, assuming the peer-reviewed manuscripts for these recently positive endovascular acute stroke trials (MR CLEAN and ESCAPE) are accepted by the community as definitive evidence for endovascular therapy. “Getting all endovascular-eligible patients triaged to endovascular–capable hospitals as quickly as possible,” she said. “Time to angiographic reperfusion will be critical. We’ll also need to build consensus on the most appropriate patient selection criteria for endovascular therapy based on these pending publications.”

Pooja Khatri, MD is Director of the Acute Stroke Program, University of Cincinnati Stroke Team.

M. Shazam Hussain, MD is Head, Cleveland Clinic Stroke Program