What is the critical appraisal of the DISAL (Distal Intracranial Stenosis and Acute Limb Ischemia) trial regarding endovascular treatment for stroke due to occlusion of medium or distal cerebral vessels?

From the Guidelines

The DISAL trial is not directly mentioned in the provided evidence, however, the critical appraisal of endovascular treatment for stroke due to occlusion of medium or distal cerebral vessels can be inferred from the guidelines and studies on endovascular treatment for acute ischemic stroke.

• The 2015 American Heart Association/American Stroke Association guidelines 1 provide an update on the endovascular treatment of acute ischemic stroke, including the use of stent retrievers and other devices.
• The guidelines discuss the importance of patient selection, including the use of advanced imaging techniques to identify patients who are most likely to benefit from endovascular treatment.
• The Canadian Stroke Best Practice Recommendations for Acute Stroke Management 1 also discuss the use of endovascular treatment for acute ischemic stroke, including the potential benefits and risks of treatment.
• The management of acute ischemic stroke due to large-vessel occlusion is discussed in the Journal of the American College of Cardiology 1, including the importance of rapid treatment and the use of endovascular therapy.
• The evidence suggests that endovascular treatment can be effective for acute ischemic stroke, but the treatment window and patient selection are critical factors in determining outcomes.
• The use of stent retrievers and other devices has been shown to be safe and effective in several studies, but further research is needed to determine the optimal treatment strategies for medium or distal cerebral vessel occlusions.
• In clinical practice, the decision to use endovascular treatment for stroke due to occlusion of medium or distal cerebral vessels should be made on a case-by-case basis, taking into account the individual patient's characteristics and the potential benefits and risks of treatment.

From the Research

Critical Appraisal of the DISAL Trial

The DISAL trial is not directly mentioned in the provided studies, but the evidence regarding endovascular treatment for stroke due to occlusion of medium or distal cerebral vessels can be summarized as follows:

• The efficacy of endovascular therapy (EVT) for distal medium vessel occlusions (DMVOs) is still being researched, with some studies suggesting a potential benefit over best medical therapy (BMT) 2, 3.
• A systematic review and meta-analysis found that EVT achieved significantly better odds of functional independence than BMT, but there were no significant differences in excellent functional outcomes, symptomatic intracranial hemorrhage, and mortality 2.
• Another study reported that microcatheter aspiration thrombectomy (MAT) is a technically feasible and effective treatment for DMVOs in the MCA territory, with a lower hemorrhagic complication rate compared to stent retriever-based thrombectomy 3.
• A randomized controlled trial found that EVT did not result in a lower level of disability or a lower incidence of death than BMT alone in persons with stroke with occlusion of medium or distal vessels 4.
• A systematic review and meta-analysis comparing stent retrievers (SR) and aspiration catheters (AC) in patients with AIS-DMVO found that SR/PC achieved higher odds of functional independence and lower odds of mortality than AC, but similar odds of successful/excellent recanalisation and symptomatic intracranial haemorrhage 5.
• A study on mechanical thrombectomy of M2 occlusions with distal access catheters using ADAPT found that DACs can safely be used for mechanical thrombectomy of acute M2 occlusions, with a high success rate and no symptomatic intracranial hemorrhage 6.

Key Findings

• EVT may have a potential benefit over BMT for DMVOs, but further research is needed to confirm this.
• MAT is a feasible and effective treatment for DMVOs in the MCA territory.
• SR/PC may have an advantage over AC in terms of functional independence and mortality, but further trials are necessary to validate this.
• DACs can be safely used for mechanical thrombectomy of acute M2 occlusions using ADAPT.

Implications

• The use of EVT for DMVOs may be considered as a potential treatment option, but the decision should be made on a case-by-case basis.
• Further research is needed to determine the optimal treatment strategy for DMVOs, including the choice of device and technique.
• The results of the DISAL trial, if available, would provide valuable insights into the efficacy and safety of EVT for DMVOs.