Endovascular Treatment for Acute Ischemic Stroke

Abstract

BACKGROUND In patients with ischemic stroke, endovascular treatment results in a higher rate of recanalization of the affected cerebral artery than systemic intravenous thrombolytic therapy. However, comparison of the clinical efficacy of the two approaches is needed. METHODS We randomly assigned 362 patients with acute ischemic stroke, within 4.5 hours after onset, to endovascular therapy (intraarterial thrombolysis with recombinant tissue plasminogen activator [t-PA], mechanical clot disruption or retrieval, or a combination of these approaches) or intravenous t-PA. Treatments were to be given as soon as possible after randomization. The primary outcome was survival free of disability (defined as a modified Rankin score of 0 or 1 on a scale of 0 to 6, with 0 indicating no symptoms, 1 no clinically significant disability despite symptoms, and 6 death) at 3 months. RESULTS A total of 181 patients were assigned to receive endovascular therapy, and 181 intravenous t-PA. The median time from stroke onset to the start of treatment was 3.75 hours for endovascular therapy and 2.75 hours for intravenous t-PA (P<0.001). At 3 months, 55 patients in the endovascular-therapy group (30.4%) and 63 in the intravenous t-PA group (34.8%) were alive without disability (odds ratio adjusted for age, sex, stroke severity, and atrial fibrillation status at baseline, 0.71; 95% confidence interval, 0.44 to 1.14; P = 0.16). Fatal or nonfatal symptomatic intracranial hemorrhage within 7 days occurred in 6% of the patients in each group, and there were no significant differences between groups in the rates of other serious adverse events or the case fatality rate. CONCLUSIONS The results of this trial in patients with acute ischemic stroke indicate that endovascular therapy is not superior to standard treatment with intravenous t-PA. (Funded by the Italian Medicines Agency, ClinicalTrials.gov number, NCT00640367.)

Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke

“…This represents a major difference from the prior clinical trials on endovascular treatment, which used clinical criteria, such as the National Institute of Health Stroke Scale (NIHSS) score, and failed to demonstrate clinical benefit 21,22,23 . In the Interventional Management of Stroke III trial (IMS-3), patients were mainly selected based on an NIHSS ≥10, and one third of them eventually did not have a target occlusion on catheter angiography.…”

“…This choice was driven by the findings of SWIFT and TREVO-2, two head-to-head randomized clinical trials comparing the reperfusion performance of stent retrievers against the MERCI device, where stent retrievers yielded a four-times higher chance of post-procedure reperfusion and higher rates of good clinical outcome 32,33 . Indeed, prior trials that did not show benefit of endovascular treatment used other first generation mechanical thrombectomy devices (mainly the MERCI device) or intra-arterial injection of TPA 21,22,34 . One assumed reason for the absence of clinical benefit in those earlier trials was the low rate of successful reperfusion.…”

Thrombectomy vs. Systemic Thrombolysis in Acute Embolic Stroke with High Clot Burden: A Retrospective Analysis

“…Previous studies compared intraarterial thrombectomy to standard stroke treatment in acute stroke patients. Three randomized controlled trials failed to show clinical benefit by intraarterial treatment [7,8,17]. The inclusion criteria are discussed as a reason for this failure, but the main factor seems to be the low recanalization rate of 27 % to 41 % in the IMS-III and MR RESCUE trial.…”

Statement of ESMINT and ESNR regarding recent trials evaluating the endovascular treatment at the acute stage of ischemic stroke

“…Three recent, simultaneous publications report the neutral results of three randomized studies (SYNTHESIS Expansion, Interventional Management of Stroke (IMS) III, and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE)) comparing IV thrombolysis therapy or standard care (MR RESCUE) to the endovascular treatment (EVT) of acute ischemic stroke (AIS) [1][2][3]. The results of these three trials might lead to the erroneous conclusion that endovascular treatment has no or little place in the management of AIS.…”