Endovascular Therapy still "reasonable" option for patients with acute stroke

Despite recent discouraging results, endovascular treatment is still a "reasonable" treatment option for selected patients with acute stroke, according to a commentary in the August issue of Neurosurgery, official journal of the Congress of Neurological Surgeons. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

A special article in the August Neurosurgery suggests that the US supply of neurosurgeons is inadequate to meet the demand, while a new study finds no evidence that obesity causes worse outcomes in patients with subarachnoid hemorrhage (SAH), a life-threatening type of stroke.

Endovascular Therapy Does Have Benefits in Some Stroke Patients
In the commentary, Dr. Alexander A. Khalessi of University of California, San Diego, and colleagues provide clinical perspective on endovascular treatment of stroke with large vessel occlusion (LVO). These procedures use nonsurgical endovascular techniques to extract the clot blocking blood flow to the brain. Three recent, highly publicized studies reported that endovascular treatment doesn't improve outcomes, compared to standard care.

"However, endovascular intervention did in fact demonstrate benefit when used in the correct clinical context within these trials," Dr. Khalessi and coauthors write. They note endovascular treatment provided better results in patients with LVO stroke confirmed by imaging studies, and in patients with more severe stroke.

From this perspective, "[C]urrent data strongly support the reasonable offering of endovascular therapy for patients with LVO," the commentators conclude. They urge further studies, building on the results of the previous trials.

US Faces Shortage of Neurosurgeons
In a special article, Dr. William T. Couldwell of University of Utah and colleagues re-evaluate evidence on the necessary supply of neurosurgeons in the United States. A commonly cited figure of one neurosurgeon per 100,000 population —based on a study from the late 1970s — appears to be outdated.

The researchers estimate the current ratio at about one per 66,000 population. But that's probably still not enough, as there are currently more than 300 open jobs for neurosurgeons. Based on the rate of new trainees, the researchers estimate it will take three years to meet that demand.

Demand "should be reevaluated by region and subspecialty to consider changes in neurosurgery practice," Dr. Couldwell and coauthors write. They note that many of the current job openings reflect a need for emergency coverage.

No Direct Effect of Body Weight on SAH Survival
A study by Dr. Johannes Platz and colleagues of Johann Wolfgang Goethe-University in Germany looked for evidence of an "obesity paradox," with better survival in SAH patients who are obese or overweight. Upon reviewing more than 700 SAH patients, they found that the rate of good outcomes was slightly lower in patients who were overweight.

After adjustment for other key factors, there was no evidence that body weight affected the changes of favorable outcomes after SAH. The results do suggest that obese patients with SAH may be at higher risk of complications—this, rather than obesity itself, may predispose to worse outcomes. Compared to factors like patient age or the severity of the stroke, the effects of obesity appear "negligible," the researchers conclude.