Interventional Treatment of Acute Ischemic Stroke:
Introduction
Kyra Becker, MD; David Fiorella, MD, PhD
T he only treatment shown to improve outcome in acute
ischemic stroke is tissue-type plasminogen activa-
tor administered within 3 hours (and perhaps longer) after
stroke onset.13 Definitive data to support a role for acute
endovascular stroke therapy, however, are lacking. Despite
this lack of data, endovascular therapy is being used much
more widely and has become the standard of care in many
regions of the United States. The need for randomized con-
trolled trials to test devices in acute stroke is hotly debated,
Downloaded from http://stroke.ahajournals.org/ by guest on November 18, 2017
but results from recent studies suggest that surgical and
endovascular interventions are not nearly as effective or safe
as had been assumed.4,5 Preconceived notions about how to
select the most appropriate patients for therapy may be simi-
larly flawed.
The articles in this section address the preclinical testing
of devices intended for endovascular use in the treatment of
stroke and the clinical use of those devices in patients with
stroke. What is clear from the data is that the devices have
become more effective over the course of time, whether this
increase in effectiveness translates into an increase in efficacy
remains to be seen.6 Finally, biases in clinical decision making
and the issue of clinical equipoise are discussed. A persuasive
argument for relying on actual data rather than recent clinical
experience, intuition, and the expert community is made, and
that data come from well-executed randomized controlled tri-
als. In the past few years, the stroke literature is replete with
examples of carefully done science refuting commonly held
beliefs.4,5,7 On the basis of the results of these trials, proof of
clinical efficacy should be required before an intervention
becomes standard of care. In the words of Mark Twain, It
Received November 28, 2012; accepted March 4, 2013.
From the Department of Neurology and Neurological Surgery, University of Washington School of Medicine, Seattle, WA (K.B.); and Department of
Neurological Surgery and Radiology, Stony Brook University Medical Center, Stony Brook, NY (D.F.).
Correspondence to Kyra Becker, MD, University of Washington School of Medicine, Seattle, WA. E-mail kjb@uw.edu
(Stroke. 2013;44[suppl 1]:S2.)
2013 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
S2
aint what you dont know that gets you into trouble. Its what
you know for sure that just aint so.
Disclosures
None.
References
1. Tissue plasminogen activator for acute ischemic stroke. The National
Institute of Neurological Disorders and Stroke rt-pa stroke study group.
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2. Hacke W, Kaste M, Bluhmki E, Brozman M, Dvalos A, Guidetti D,
et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours
after acute ischemic stroke. N Engl J Med. 2008;359:13171329.
3. Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G,
et al. The benefits and harms of intravenous thrombolysis with recombi-
nant tissue plasminogen activator within 6 h of acute ischaemic stroke
(the third international stroke trial [IST-3]): a randomised controlled
trial. Lancet. 2012;379:23522363.
4. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane
BF, et al; SAMMPRIS Trial Investigators. Stenting versus aggres-
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2011;365:9931003.
5. Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr,
Derdeyn CP; COSS Investigators. Extracranial-intracranial bypass
surgery for stroke prevention in hemodynamic cerebral ischemia: the
Carotid Occlusion Surgery Study randomized trial. J Am Med Assoc.
2011;306:19831992.
6. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al;
SWIFT Trialists. Solitaire flow restoration device versus the Merci
Retriever in patients with acute ischaemic stroke (SWIFT): a randomised,
parallel-group, non-inferiority trial. Lancet. 2012;380:12411249.
7. Furlan AJ, Reisman M, Massaro J, Mauri L, Adams H, Albers GW, et al;
CLOSURE I Investigators. Closure or medical therapy for cryptogenic
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Key Words: devices endovascular ethics intervention stroke
thrombectomy
DOI: 10.1161/STROKEAHA.111.000283
 Interventional Treatment of Acute Ischemic Stroke: Introduction
Kyra Becker and David Fiorella

Stroke. 2013;44:S2
Downloaded from http://stroke.ahajournals.org/ by guest on November 18, 2017

doi: 10.1161/STROKEAHA.111.000283
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