Does Clot Retrieval Work in Stroke?

Mark J. Alberts, MD


March 31, 2011

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Hello. I'm Dr. Mark Alberts, Professor of Neurology at Northwestern University and Director of the Stroke Program at Northwestern Memorial Hospital in Chicago. Welcome to this Medscape stroke update.

Today I wanted to share with you some information that was presented at the recent International Stroke Conference held in Los Angeles in February 2011. This will be the first of a number of updates because several studies were presented at the stroke meeting that I wanted to share with you.

The first is a presentation about the results of the MERCI [Mechanical Embolus Removal in Cerebral Ischemia] registry.[1] This was presented by Dr. Marilyn Rymer. As you know, MERCI is a mechanical clot removal device and this registry included approximately 1000 patients who were enrolled from more than 30 medical centers. Essentially, all of the patients, or the vast majority, had large strokes with occlusion of the distal internal carotid artery or M1 segment of the middle cerebral artery. The median NIH [National Institutes of Health] stroke scale score was 17, indicating that they had fairly significant strokes.

Dr. Rymer reported that, overall, they were able to get the artery open in 80% of cases, which is very good. However, we don't know how many of those 80% had successful reperfusion of the distal brain tissue. It is interesting that about one third of the patients were able to achieve an independent modified Rankin of 0-2 at 3 months, and about one third of the patients died.

This is interesting because when you look at results of other treatments such as intravenous tPA [tissue plasminogen activator], the MERCI results are roughly the same in terms of 3-month outcomes. Granted, the patients enrolled in the MERCI registry were sick patients and they had large strokes. The fact that one third of them died is somewhat concerning. Dr. Rymer also reported that the patients who were intubated tended to have worse outcomes than the patients who were not intubated for the procedure. This is consistent with results of other trials.

So MERCI raises the question about whether opening up the blood vessels is a good thing; however, we still have much to learn in terms of how this translates into a good clinical outcome at the end of the day.

I want to share with you the results of another more modest trial with only 118 patients from France who had a stroke and then, after the stroke, were randomly assigned to receive either fluoxetine 20 mg daily or placebo to see how this affected their long-term outcome on a number of factors including motor function and modified brain wave.[2] This study found that after 3 months the percentage of patients who were independent with a modified Rankin of 0-2 was about 26% in the patients who received fluoxetine vs only 8% in patients who received placebo, and this difference was statistically significant.

This was a small study of only 118 patients but it does raise the prospect that perhaps acute treatment with fluoxetine, continued for at least 3 months, may improve neurologic outcome in patients with stroke. Perhaps this will lead to a larger randomized double-blind trial to see if this holds true.

This is the first in a series of Medscape stroke updates talking about some of the major trials from the International Stroke Conference in Los Angeles. In about a week or so, we'll have another update talking about new studies. Thank you very much for joining me today.


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