Not many topics in the literature have been as controversial as thrombolysis and thrombectomy in acute CVA patients. Many studies have been cited for bias due to industry sponsorship, post hoc analysis, non-clinically relevant outcome measures and heterogeneity to name a few. One question that is often cited is which subgroups of patients are the most likely to benefit from or, not be harmed by TPA or thrombectomy. For those clinicians new to EM, it is worthwhile to review the history of thrombolysis in acute CVA and thrombectomy. Those who have been around a while, have seen an evolution in the approach to managing acute stroke patients. The one area that is not controversial in managing acute stroke patients and eloquently written by my EBM colleague, Eddy Lang for the NNT is, “acute ischemic stroke treatment is best delivered by a team with expertise in emergency critical care, rapid neurological assessment, interpretation of brain imaging, and access to stroke unit care. When treatment has been attempted in the absence of a collaborative team structure, trial results have not been duplicated.” We hope you are able join us in our attempt to advance our own team approach to stroke management.

DAWN Trial Nogueira RG et al, Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.N Engl J Med. 2018 Jan 4;378(1):11-21 APPRAISAL

DEFUSE-3 Trial: Albers GW et al, Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging N Engl J Med. 2018 Feb 22;378(8):708-718.  APPRAISAL

 EXTEND Trial Ma H et al, Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke.  N Engl J Med. 2019 May 9;380(19):1795-1803 APPRAISAL