March 2025 | Issue 57
www.neuronewsinternational.com
Featured in this issue:
D/MEVO
Novel EVD catheter nets six-figure innovation prize
BRAIN conference: ICAD is ‘globally relevant yet underaddressed’ in stroke
Profile Simona Sacco
Medtech Insights: Could reversible thrombolytic alleviate tPA ‘tribalism’?
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Multiple trials find no clinical DISTAL findings in 2021, the DISTAL benefit with stroke Launched trial investigated whether thrombectomy thrombectomy in addition to best medical therapy—often including for distal- and intravenous thrombolytics—was able to reduce disability compared medium-vessel to best medical therapy alone. The trial included 543 adult patients who occlusions entered one of 55 hospitals across
Three randomised trials presented at the International Stroke Conference (ISC; 5–7 February, Los Angeles, USA) have indicated that mechanical thrombectomy treatments confer no advantages over the current standard of care for acute ischaemic strokes caused by distal- or mediumvessel occlusions (D/MeVOs). Final analyses of the DISTAL and ESCAPE-MeVO studies revealed that thrombectomy failed to produce an improvement in patients’ clinical outcomes, while the DISCOUNT study was halted early due to safety concerns and indications of futility with the procedure.
“F
that thrombectomy for distal-vessel occlusions should not be an assumed default care pathway.”
ew procedures have gone through a decade of practicechanging clinical trials as impressive as thrombectomy for stroke,” writes J Mocco (Mount Sinai Health System, New York City, USA) in an editorial accompanying the publication of DISTAL and ESCAPE-MeVO in the New England Journal of Medicine (NEJM). “Beginning in 2015 with multiple trials showing a benefit with thrombectomy in early large-vessel occlusion, followed by the extended-window trials in 2018 and then the largecore trials in 2023, it seemed that no corner of the cerebrovasculature would not have a substantial benefit from a proper clot removal—until now. “No matter how one considers these data, there is no question PROXIMAL that they represent the current ground zero of evidence to inform decisionmaking regarding the use of thrombectomy for stroke due to medium- and distal-vessel occlusion. The data clearly show
Europe with disabling stroke symptoms. Imaging tests confirmed a medium/distal vessel blockage in all participants, with patients subsequently being randomly selected to receive either standard stroke care only or standard care plus thrombectomy treatment. The effectiveness of thrombectomy treatment was measured via the patients’ disability and need for assistance in daily activities (modified Rankin scale [mRS]) at 90 days post-stroke, with decisions about the exact devices and procedures used for thrombectomy being left to the treating physician. Ninety-day follow-up analysis of DISTAL revealed that there was no significant difference in disability between those receiving DISTAL thrombectomy plus standard medical care and those receiving standard medical care alone. In addition, there were similar rates of death for each group—15.5% for those receiving thrombectomy plus standard medical care versus 14% among those receiving standard medical care alone—while rates of severe symptomatic brain bleeds were 5.9% for those receiving thrombectomy plus standard medical care versus 2.6% with standard medical care alone. This lack of added benefit with thrombectomy was confirmed when researchers analysed specific subsets of people, such as those who did not receive intravenous thrombolytic medications and those who had more severe strokes. “We were surprised at the Continued on page 2
EVT’s role in large-core stroke ‘reframed’ by recent data A NEW SCIENTIFIC ADVISORY from the American Heart Association (AHA), published recently in Stroke, has reviewed clinical data from six randomised controlled trials evaluating endovascular therapy (EVT) in the treatment of ischaemic strokes caused by large-core infarctions, and ultimately concludes that these data “reframe” the role for reperfusion therapies in this population. The advisory details that the trials— ANGEL-ASPECT, LASTE, RESCUEJapan LIMIT, SELECT2, TENSION and TESLA—provide “strong evidence” supporting the benefits of EVT in patients with a good pre-stroke functional status and significant stroke severity, as per initial imaging of the extent of their ischaemia. The trials enrolled a total of 1,887 patients across global geographies including Australia, Canada, China, Japan, New Zealand, the USA, and several countries in Europe, evaluating the efficacy of EVT alongside standard medical management—as compared to medical management alone—in large-core ischaemic stroke. “The results of these six trials reframe current evidence regarding the role of reperfusion therapies in those with larger areas of presumed irreversible ischaemia,” the advisory states. “The benefit of EVT in this setting may reflect the prevention of further infarct expansion or potentially improved tissue outcomes within ischaemic beds. Further research is needed to elucidate the mechanisms at play.”