Neurology Practice Changers 2014

Bret S. Stetka, MD; Andrew N. Wilner, MD


December 08, 2014

In This Article

Polishing Stroke Outcomes

More recently, the results of the Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in The Netherlands—or MR CLEAN—trial were presented at the Ninth World Stroke Conference in Istanbul, Turkey.[4] The study showed that intra-arterial treatment is safe and effective for patients with acute ischemic stroke caused by an intracranial arterial anterior-circulation occlusion when given within 6 hours of stroke onset. Study results are thus far available only in abstract form, but the study design was previously published.[5]

Prior studies—the SYNTHESIS Expansion trial,[6] the MR RESCUE trial,[7] and the IMS-III trial[8] —showed no benefit of using endovascular therapy, in combination with or instead of tissue plasminogen activator (tPA), in patients with acute ischemic stroke. But in the new research, study investigator Diederik Dippel, MD, PhD, senior consultant in the department of neurology at Erasmus Medical Center in Rotterdam, The Netherlands, set out to assess the efficacy of endovascular therapy in the setting of optimal medical management, including improved patient selection using CT, rapid access to treatment at Dutch stroke units, and the latest endovascular treatment approaches.

Dippel enrolled 500 stroke patients; those in the endovascular treatment group underwent intra-arterial therapy within 6 hours from the onset of symptoms. Functional outcomes were assessed at 90 days by phone interview and by modified Rankin Scale and the Barthel index to quantify level of disability. The intervention was of intra-arterial alteplase or urokinase and/or mechanical treatment, consisting of thrombus retraction, aspiration, sonolysis, or use of a retrievable stent. The control group received standard stroke care, which included intravenous alteplase (tPA) in nearly all patients (91%).

After endovascular treatment, more patients shifted to a lower category of modified Rankin score, with an adjusted odds ratio of 1.67 vs the control group. Benefit after endovascular treatment occurred in all age groups. Endovascular treatment resulted in recanalization in 80% of patients at 24 hours vs 32% of the control group (adjusted odds ratio, 6.9; 95% confidence interval, 4.3-10.9). After 1 week, infarct volumes after endovascular treatment were 49 ml vs 80 mL for controls.

When the data were analyzed by presenting National Institutes of Health Stroke Scale (NIHSS) scores, only patients with the most severe strokes (NIHSS score ≥ 20) had benefit, with an adjusted odds ratio of 1.85. Serious adverse events occurred in 47% of the endovascular group vs 42% of the controls; these events included new ischemic stroke in a different vascular territory in 5.6% of endovascular therapy recipients vs 0.4% of controls.

This study demonstrates that endovascular therapy may benefit stroke patients, including those treated with tPA, who present with severe neurologic deficits. The positive results of this trial, in contrast to prior endovascular trials, may be related at least in part to more modern endovascular devices and their prompt application: The time from stroke onset to groin puncture was only 260 minutes. In addition, procedures had to be stopped after 8 hours from symptom onset. Prompt treatment was no doubt facilitated by the fact that The Netherlands is a small country, in which most of the population lives within half an hour of one of the 30 participating stroke centers.


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