The HERMES (Highly Effective Reperfusion and Minimally Invasive Endovascular Stroke Treatment) trial represents a significant advancement in our understanding and treatment of acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) in the anterior circulation. This landmark study, published in the *New England Journal of Medicine* (NEJM), significantly impacts the clinical landscape of stroke care, particularly concerning the selection of patients who may benefit most from endovascular thrombectomy (EVT). While previous trials like DAWN and DEFUSE 3 established the efficacy of EVT in patients with prolonged ischemic times and mismatch between infarct core and penumbra, HERMES delves deeper into refining patient selection criteria and optimizing treatment strategies. This article will examine the HERMES trial within the broader context of large core stroke trials, focusing on its methodology, findings, and implications for clinical practice and future research directions, specifically addressing its relationship to other pivotal trials like the SELECT 2 trial and the SPEEDY stroke trial.
The NEJM Select Trial and the Context of Large Core Stroke Trials:
The HERMES trial sits within a series of progressively refined NEJM-published trials focused on improving outcomes in acute ischemic stroke. These trials, including DAWN, DEFUSE 3, and now HERMES, represent a crucial evolution in our approach to managing large core strokes. Prior to these trials, the prevailing dogma largely excluded patients with extensive infarct core volumes from receiving EVT, primarily due to concerns about irreversible brain damage. However, these studies demonstrated that even in patients with seemingly large infarcts, timely reperfusion could still yield significant clinical benefits. This paradigm shift was driven by the concept of the "mismatch" between the irreversibly damaged core and the potentially salvageable penumbra.
Large core stroke trials, such as HERMES, are characterized by their focus on patients with substantial infarct volumes, challenging the traditional limitations of EVT. These trials utilize advanced neuroimaging techniques, such as perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI), to delineate the infarct core and penumbra, providing a more nuanced understanding of the extent of brain injury and the potential for recovery. This sophisticated imaging allows for a more precise assessment of the mismatch ratio, a key factor in determining patient eligibility for EVT.
HERMES Trial Methodology: A Refinement of Selection Criteria:
The HERMES trial, like its predecessors, employed a randomized controlled trial (RCT) design. Patients with acute ischemic stroke due to proximal anterior circulation LVO were randomly assigned to receive either endovascular thrombectomy or standard medical management (IV thrombolysis followed by medical management). However, a key distinguishing feature of HERMES lies in its refined inclusion criteria. While encompassing patients with large infarct cores, HERMES focused on a specific subset of patients within this population, potentially optimizing the selection process for EVT. This focused approach helps to refine our understanding of the optimal patient population that will benefit from this procedure. The specific criteria used in HERMES for patient selection need to be clearly detailed here to provide a complete understanding of the trial's methodology and its implications. [This section requires specific details from the HERMES study publication to be completed accurately. Information on the exact inclusion/exclusion criteria, imaging protocols, and procedural techniques should be included here.]
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