IMS-III and synthesis expansion trials of endovascular therapy in acute ischemic stroke how can we improve?

摘要

The recent results of the Interventional Management of Stroke m (IMS-HI)1 and SYNTHESIS Expansion2 trials have brought forth a hard wave of skepticism on the use of endovascular therapy in acute ischemic stroke reinforcing more than ever the nihilistic behavior that has afflicted this field since its inception.As research results are only generalizable to a similar cohort to the target study population, it is imperative to acknowledge the existence of 3 distinct populations of patients with large vessel occlusion stroke (LVOS): (1) intravenous tissue-type plasminogen activator (tPA) eligible (0-3-4.5 hours), further categorized in intravenous tPA responders and intravenous tPA refractory patients; (2) early presenting intravenous tPA ineligible patients (0-6 hours); and (3) late presenting and unknown time of onset patients (6-24 hours including wake-up). IMS-Ill and SYNTHESIS have only focused on intravenous tPA eligible patients, and therefore their results cannot be applied to intravenous tPA ineligible patients. This is an important notion because only ?40% to 50% of the patients who currently undergo thrombectomy receive prior intravenous tPA.45 Notably, there is currently level IB evidence to support intra-arterial thrombolysis in early presenting LVOS (0-6 hours),6 and the results of IMS-HI and SYNTHESIS do not apply to most of these patients.