COMMENTARY

Benefits Sustained After Endovascular Treatment for Stroke

Lauri L. Barclay, MD

Disclosures

May 12, 2017

Two-Year Outcome After Endovascular Treatment for Acute Ischemic Stroke

van den Berg LA, Dijkgraaf MG, Berkhemer OA, et al; MR CLEAN Investigators
N Engl J Med. 2017;376:1341-1349.

Summary

At 90 days after endovascular treatment for acute ischemic stroke, functional outcomes have been better than with conventional treatment, based on findings from several trials. However, few studies have addressed long-term clinical outcomes. In this randomized trial, 500 patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation were assigned to receive endovascular intervention or conventional treatment.

Functional status at 2 years was the primary outcome (n = 391; 78.2%), based on modified Rankin scale score (range, 0 [no symptoms] to 6 [death]). All-cause mortality among 459 patients (91.8%) and quality of life at 2 years were secondary outcomes. A health utility index based on the European Quality of Life-5 Dimensions questionnaire (score range, -0.329 to 1, with higher scores reflecting better health) measured health-related quality of life.

Compared with conventional treatment, endovascular intervention was associated with better distribution of outcomes on the modified Rankin scale (adjusted common odds ratio, 1.68; 95% confidence interval [CI], 1.15 to 2.45; P = .007). However, the percentage of patients with an excellent outcome (modified Rankin scale score of 0 or 1) did not differ significantly between the treatment groups.

Patients receiving endovascular intervention also fared better than those receiving conventional treatment on mean quality-of-life score (0.48 vs 0.38; mean difference, 0.10; 95% CI, 0.03 to 0.16; P = .006). Cumulative 2-year mortality rate did not differ significantly between the treatment groups (26.0% vs 31.0%; adjusted hazard ratio, 0.9; 95% CI, 0.6 to 1.2; P =.46). The rate of major vascular events between 90 days and 2 years was low (1.6% in 474 person-years at risk).

Viewpoint

The study limitations include powering of the original trial to detect an effect only at 90 days, lack of accounting for dropouts during the 2-year follow-up, and possible selection bias. Nonetheless, this extended follow-up trial showed that the overall benefit of endovascular treatment in patients with acute ischemic stroke was sustained for at least 2 years, with an impact on functional outcome at 2 years similar to that reported at 90 days in the original trial.

The odds ratio for better scores on the modified Rankin scale in the endovascular vs conventional treatment group was 1.67 at 90 days and 1.68 at 2 years. Functional independence, with a modified Rankin scale score of 0 to 2, at 2 years was comparable to that at 90 days (37.1% vs 32.6%). At 90 days, both groups had similar mortality, whereas there was a nonsignificant trend toward lower mortality at 2 years with endovascular intervention.

The results confirm and extend those of other studies of reperfusion therapy for ischemic stroke, which suggest that time does not attenuate the benefits of intravenous alteplase and of endovascular treatment. Overall, the findings further support use of endovascular treatment for appropriate patients with acute ischemic stroke.

Abstract

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