Adjunctive Steroids as Stroke Reperfusion Strategy

Abstract

With recent advances in endovascular devices and techniques for the treatment of large-vessel occlusion (LVO) stroke, rates of successful recanalization are as high as 90%. 1 While technologies may continue to improve, it would be unreasonable to anticipate significant gains in this measure of macroperfusion. Instead, efforts are increasingly turned toward neuroprotection and augmenting the microcirculation to promote tissue viability during acute cerebral ischemia. Adjunctive intra-arterial thrombolysis 2 and the recombinant variant of human activated protein C (3K3A-APC) 3 have shown promising preliminary results, but warrant additional validation. Inflammatory mechanisms following acute cerebral infarction are also the subject of much clinical research. Following acute ischemic stroke, there is robust activation of peripherally circulating and central immune cells that contribute to cytotoxic and vasogenic edema, leading to progressive tissue injury, hemorrhagic transformation, and ultimately poorer clinical outcomes. 4 The evidence that heightened acute inflammation mediates poor outcomes following infarction is also supported by evidence suggesting potential benefit of anti-inflammatory treatments including the toll-like receptor 4 antagonist ApTOLL, 5 and the combination antioxidant/anti-inflammatory compound edaravone dexborneol 6 in acute cerebral infarction; however, more research is needed.In this issue of JAMA, the MARVEL Investigators explore the potential benefits of acute anti-inflammatory treatment in patients with acute stroke treated with endovascular thrombectomy by randomizing patients with acute LVO of the internal carotid or proximal middle cerebral artery to intravenous methylprednisolone or placebo. 7 Patients were eligible for inclusion if they had severe stroke-related deficits as defined by a National Institutes of Health Stroke Scale (NIHSS) score of 6 or greater and early evidence of ischemic injury on the baseline computed tomography (CT) scan, as measured by the Alberta Stroke Program Early CT Score (ASPECTS) of 3 or greater (where 3 indicates as much as 70% of the middle cerebral artery territory showing ischemic changes). The primary efficacy outcome was the distribution in functional disability at 90 days using the modified Rankin Scale (mRS), with scores ranging from 0 to 6, where 0 represents no symptoms, 2 represents the inability to carry out all activities of daily living but remaining independent, and 6 indicates death.Among the 1687 included patients treated across the 82 sites in China, the stroke severity according to the NIHSS score was expectedly high (median, 19 [IQR,(16)(17)(18)(19)(20)(21)), with a median ASPECTS of 6 (IQR, 4-7). Regarding the primary outcome of a shift in the distribution of the mRS score 90 days after stroke,