Tuesday, January 20, 2015

The impact of MR CLEAN Editorial IJS

The impact of MR CLEAN 
This is the first opportunity I've had to comment on the recent presentation of the MR CLEAN results by Dr Diedrick Dippel from the Netherlands at the World Stroke Congress in Istanbul, 2014. As the stroke world now knows, the results of this well conducted randomized control trial of endovascular treatment in acute ischaemic stroke, most of whom had commenced intravenous tPA before randomization, was strongly positive. For the first time in my career I observed a standing ovation following a presentation, such was its impact. To have such a clear-cut result, after years of frustration with trials of neuro protection and even endovascular therapy, we now seem to be at a point where the second definite intervention of acute ischemic stroke is upon us. While it is true that we have two other proven interventions for acute ischaemic stroke vis management in a stroke unit and hemicraniectomy, endovascular therapy promises to be the most significant advance in the area since tPA in 1995–96.
Interestingly, the Data safety monitoring boards of trials such as EXTEND IA, SWIFT–PRIME and ESCAPE, reacting to the MR CLEAN results have suggested suspension of these trials, with steering committees recommending these trials now cease, the final results of many will be presented at the forthcoming ISC in Nashville, USA, this month.
More importantly, if the results of MRCLEAN are confirmed by other studies, a revolution of the delivery of stroke services is likely to occur. Specifically, the demand for interventional services is going to escalate almost exponentially so that centres of excellence will need to be established to cope with the throughput to maintain their high standards of excellence in service delivery. Governments around the world will need to response accordingly.
Taking a look at this edition, Patrick Lydens review Revisiting Cerebral Postischemic Reperfusion Injury: New Insights highlights that there is still much research to do to fully understand this process and offers targets for therapy as yet to be identified, the relevance relating to my earlier comments on endovascular therapy is obvious. Since with both tPA and endovascular therapy reperfusion injury is going to become an increasingly important topic; a review well worth reading. I also mentioned how surgical decompression for space-occupying middle cerebral artery infarction has become one of the proven interventions of definite benefit after acute ischemic strokes, albeit in a minority of patients. Hence, the systematic review of Middelar et al is a welcome supplement to a difficult area of research. Reassuringly, quality of life was reasonable amongst most patients receiving this intervention and severe decompressive symptoms were uncommon. This provides even more evidence to suggest that the procedure be performed much more frequently than it is in most centres around the world.
Our research papers this edition are of their usual high standard, and I'm delighted to have a Panorama telling us about the burden of stroke in Mexico, our protocols section, continues to be extremely popular with trials for Cilistozol, folic acid and b vitamins, among a number of secondary prevention studies.
Looking forward to seeing you at the inaugural European Stroke Organization Conference, which is the official European Stroke Conference.

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