We are at a pivotal time in our relatively recent excursions into the world of recanalization therapies for acute ischemic stroke. The use of intravenous thrombolysis has driven changes in stroke management practices worldwide, and has now become the most accepted form of acute stroke therapy.
While this is a simple and pragmatic way to increase recanalization rates and improve outcomes, we are now in the era of a much more sophisticated approach to the most obvious ways of improving stroke outcomes, viz; unblocking arteries. A number of recently completed trials of endovascular devices were to be the next big thing but have all been disappointing in a number of ways.
The Leading Opinion by Hacke and Furlan addresses this issue nicely. I agree with their stance that if data from the clot retrieval trials are examined carefully, important positives can be identified. Particularly, that large carotid T or M1 recanalization done early improves outcomes.
There is no doubt that earlier is better, and trial within later time windows need to be done within the context of an understanding of the status of tissue viability assessed by various imaging parameters. So rather than the results of the recent trials of endovascular therapy being a barrier, they represent an opportunity to design better and bigger trials more likely to produce positive outcomes.
This edition has a thrombolytic theme with commentary also on the true place of the reversibility of the DWI lesions by Campbell et al., and supported by the findings of Sakamoto et al. Early ischemic diffusion lesion reduction in patients treated with intravenous tissue–plasminogen activator: infrequent, but significantly associated with recanalization showing that only a modest proportion of patients have this imaging feature, and is often reversible. We are also pleased to be publishing the Statistical analysis plan (SAP) for the second INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial (INTERACT2): a large-scale investigation to solve longstanding controversy over the most appropriate management of elevated blood pressure (BP) in the hyperacute phase of intracerebral haemorrhage (ICH), which is a very interesting piece, especially now that the INTERACT 2 results were released at the European Stroke Conference (ESC) in London.
In keeping with our aim to embrace the global world of stroke, we have two interesting Panorama pieces in this edition that make fascinating reading. Stroke care in Central Eastern Europe: current problems and call for action and the Burden of stroke in Estonia.
As stroke care improves in all areas of the globe, sharing experiences such as these is an invaluable lesson for us all.