In Brazil, stroke has been a neglected disease and the first cause of mortality for decades¹1 Martins SC, Pontes-Neto OM, Alves CV, Freitas, GR, Oliveira Filho J, Tosta ED et al. Past, present, and future of stroke in middle-income countries: the Brazilian experience. Int J Stroke. 2013;8(Suppl A100):106-11. doi:10.1111/ijs.12062. After recent advances on stroke policies and practices, stroke has now dropped to the second cause of mortality¹1 Martins SC, Pontes-Neto OM, Alves CV, Freitas, GR, Oliveira Filho J, Tosta ED et al. Past, present, and future of stroke in middle-income countries: the Brazilian experience. Int J Stroke. 2013;8(Suppl A100):106-11. doi:10.1111/ijs.12062^,22 Ministério da Saúde (BR), Datasus. Mortalidade. Brasília, DF: Ministério da Saúde. [cited 2015 Aug 15]. Available from: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/obt10uf.def
http://tabnet.datasus.gov.br/cgi/deftoht... ^,33 Pontes Neto OM. Stroke awareness in Brazil: what information about stroke is essential? Arq Neuropsiquiatr. 2014;72(12):909-10. doi:10.1590/0004-282X20140197^,44 Cabral N, Conforto AB. Stroke: an ongoing revolution. Arq Neuropsiquiatr. 2015;73(10):892-3. doi:10.1590/0004-282X20150129. A small victory, but we are still far from winning the war against this condition. Less than 1% of stroke patients in Brazil have access to intravenous thrombolysis and admission to a stroke unit¹1 Martins SC, Pontes-Neto OM, Alves CV, Freitas, GR, Oliveira Filho J, Tosta ED et al. Past, present, and future of stroke in middle-income countries: the Brazilian experience. Int J Stroke. 2013;8(Suppl A100):106-11. doi:10.1111/ijs.12062. In this context, how are we to face the dawn of a new era of endovascular therapy (EVT) for ischemic stroke?

Five recent clinical trials (MR CLEAN, EXTEND-IA, ESCAPE, SWIFT-PRIME and REVASCAT) conveyed clear evidence that EVT produces massive clinical benefits to selected stroke patients⁵5 Smith EE, Schwamm LH. Endovascular clot retrieval therapy: implications for the organization of stroke systems of care in North America. Stroke.2015;46(6):1462-7. doi:10.1161/STROKEAHA.115.008385. Taken together, these results establish a new standard-of-care for around 20% of stroke patients, those with a proximal artery occlusion. Nevertheless, some additional corollaries need to be considered in Brazil⁶6 Castro-Afonso LH, Abud TG, Pontes-Neto OM, Monsignore LM, Nakiri GS, Cougo-Pinto, PT et al. Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population. Clinics. 2012;67(12):1379-86..

First, these exciting results were obtained at high-volume comprehensive stroke centers with large experience with stroke therapy with TPA (including telemedicine) and full-time stroke teams (with a stroke neurologist), angiography suite and multimodal neuroimaging. The reproducibility of their results in our healthcare system requires organizing efficient stroke networks, able to identify candidates for EVT and promptly refer them to comprehensive stroke care center. This poses a special challenge in Brazil, given its continental dimensions, geoeconomical disparities, and paucity of such comprehensive stroke units. We also need to train a new generation of stroke neurologists and interventionalists.

Secondly, the underlying selection paradigm differed widely among trials, from being extremely restrictive in selecting patients ( eg. , EXTEND-IA) to a more pragmatical (MR CLEAN and REAVASCAT) approach (Figure). Different solutions will depend on resource availability and local expertise. New national stroke guidelines are welcomed and should provide a comprehensive backbone for the implementation of selection criteria nation-wide.

Finally, it is crucial that cost-effectiveness analyses are conducted while the treatment is made available. The net impact of EVT in the Brazilian scenario is likely to be huge, given the more severe profile of our stroke patients. A joined effort of the Brazilian stroke community is necessary to expedite the translation of scientific evidence to clinical practice in order to avoid the repetition of historic mistakes, such as the unacceptable delay for approval of public reimbursement of intravenous thrombolysis within the public health care system, which only happened almost 17 years after the publication of the NINDS trial.

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