New era of stroke therapy and new challenges

Correspondence to Zhongrong Miao; [email protected] The year 2015 was revolutionary for the treatment of acute ischaemic stroke (AIS) because of publication of multiple large randomised controlled clinical trials (RCTs) on the success of mechanical thrombectomy. Campbell et al provided a very comprehensive review of this topic in this issue of Stroke and Vascular Neurology. Consequently, the European and Chinese AIS guidelines have both given thrombectomy the highest level of recommendation (I,A). While we celebrate this most significant change in 20 years of stroke therapy, we also begin to contemplate what these new treatment modalities will bring. The first question is, should the current care protocols be changed? Intravenous thrombolysis has been widely practised in China. The number of patients treated has improved significantly in recent times. The door to needle time has been shortened to a level comparable to the international standard at many large stroke centres. However, the rate of giving intravenous tissue-type plasminogen activator (TPA) is still <10% in China and <5% of patients with stroke would arrive at the hospital within 3 h. Therefore, if we do not make significant changes to the current protocol on acute phase triaging, not many patients with AIS may benefit from these state-of-the-art thrombectomies. We especially need to improve two aspects of care processes. One is to improve dissemination of stroke education to the public, hospital administration and governmental agencies so that they can better understand the benefit of thrombectomy. The second is to standardise the training of the providers. In China, providers who can offer thrombectomy include neurologists, neurosurgeons and interventional radiologists. Their training and ways of providing interventional treatment are quite diverse. Many pursue technical and imaging goals while ignoring the importance of preoperative evaluation of patients. The published trials have taught us that preoperative evaluation of patients with stroke for their stroke subtypes, the location of the blockage, the presence of a penumbra with mismatch and the degree of collaterals is crucial and will impact their outcome. If the training of those performing thrombectomy in China is not standardised, it is perceivable that such treatment modality could be abused or misused and, therefore, lose its effectiveness. The second question is whether the research on intra-arterial (IA) thrombolysis alone should be continued? Before the arrival of mechanical thrombectomy, IA thrombolysis was one of the treatment modalities for patients with AIS. From PROACT II (Prolyse in Acute Cerebral Thromboembolism II) and MELT (Middle Cerebral Artery Embolism Local Fibrinolytic Intervention Trial Japan), we have learned that IA thrombolysis alone could improve the patient’s outcome. In China, a retrospective review also showed that IA urokinase performed better recanalisation of the arteries and improved outcome. However, these trials did not have rigorous preoperative imaging analysis and screening. Therefore, if the same preoperative screening of patients and their vasculature were implemented, such as in the ESCPE and SWIFT PRIME trials for IA thrombolysis alone, would the outcome be as good clinically? Compared to IA thrombectomy, simple IA thrombolysis is technically easier to perform and financially more economical. If urokinase is used, then the fee for the entire procedure is around 10 000 RMB. On the contrary, the use of a Solitaire FR thrombectomy device would incur a fee of around 70 000 RMB. The third question is, can the results of these well-conducted RCTs be applied to routine daily clinical practice? It is well know that every patient with stroke is different. Many patients with stroke may require multiple interventional therapies to clear the clot (Penumbra, Solitaire or thrombolysis). Individualising the treatment plan for each patient with AIS is the likely procedure in the future. For example, many patients with AIS may have in situ thrombus because of