COMMENTARY

Embolectomy for Ischemic Stroke: A Look at Outcomes

Mark J. Alberts, MD

Disclosures

August 11, 2011

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Hello. I am 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 would like to talk about 2 recent studies.

The first was published in the June 2011 edition of Stroke.[1] It was by Dr. Harry Cloft and colleagues from the Mayo Clinic. In this study they used a large administrative database to examine more than 3800 patients who had received endovascular procedures for clot removal in the setting of an acute ischemic stroke. In this large study, they found that of these more than 3800 patients, approximately 24% died and almost 50% ended up in some sort of long-term facility, typically a nursing home. Only about 25% had what we would consider a good outcome in terms of being able to go to a rehabilitation facility or home. As might be expected, age was a big predictive factor. Older patients had a higher mortality compared with younger patients. The rate of intracranial hemorrhage was 15% in patients who did not receive thrombolytic therapy in this setting vs 20% who did. However, the investigators did not explain what percentage of these patients actually had a symptomatic intracranial hemorrhage.

Nonetheless, this study gives us some pause because out of the large number of patients, only about 25% had good outcomes. The patients were typically enrolled in this database up to the year 2008. We could argue that perhaps the procedure and the efficacy and safety have improved in the intervening 3 years, but we don't have any hard data on which to base this. This is one study that gives us some pause and some areas of concern about whether it is really a good idea to do a huge embolectomy in patients with acute ischemic stroke.

The next study was published by Fiorella and colleagues[2] in the July 2011 edition of Stroke. This study reviewed outcomes from the Wingspan registry. As you may know, the Wingspan™ device (Boston Scientific, Natick, Massachussets) is meant to correct or treat intracranial stenosis. From this registry the investigators looked at 158 patients with 14 months of long-term follow-up. They found, overall, a 16% rate of the primary endpoint of stroke within 30 days and/or death, as well as long-term ipsilateral stroke. Most of these strokes occurred within the first 6 months of treatment with the Wingspan stent. Of interest, the reasons for failure were either restenosis of the stent or cessation of antiplatelet therapy.

This is another interventional procedure that is being widely used. The outcomes are moderate, with a 16% rate of short-term stroke and death and long-term ipsilateral stroke. Clearly, areas for improvement exist in the use of the Wingspan stent, and hopefully newer devices will have better safety and efficacy profiles. Thank you very much for your attention.

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