Endovascular Stroke Therapy Remains Unproven
Endovascular treatments for ischemic stroke did not improve clinical outcomes compared with medical therapy, despite higher recanalization rates, in two new studies.
Two research groups conducted randomized trials to assess the long-term effects of endovascular stroke treatment.
Ciccone and colleagues randomized 362 patients with acute ischemic stroke to either endovascular therapy (with any approved thrombectomy device and/or intra-arterial lytic) or to intravenous tissue plasminogen activator (TPA) alone. The outcome of interest disability-free survival at 90 days (modified Rankin Scale [mRS] score of 0 or 1) was 30% in the endovascular-therapy group and 35% in the intravenous TPA group, a nonsignificant difference. The results did not change after adjustment for age, sex, stroke severity, or the presence of atrial fibrillation.
In an international study by Broderick and colleagues, 656 patients received TPA within 3 hours after acute ischemic stroke. The researchers then randomly assigned two thirds of the patients to undergo angiography within 5 hours of stroke onset, followed by endovascular treatment of identified occlusions with any approved thrombectomy device or intra-arterial lytic. The trial was stopped early for futility. The two treatment approaches did not have different effects on 90-day functional outcome (mRS score ¤2; 41% with endovascular therapy, 39% with TPA alone), mortality (19% vs. 22%), or symptomatic intracerebral hemorrhage with 30 hours after TPA initiation (6.2% vs. 5.9%). Stroke severity did not alter outcomes significantly.
Comment: These studies indicate that endovascular stroke treatment with predominantly first-generation thrombectomy devices or intra-arterial lytic infusion does not improve long-term outcomes compared with intravenous TPA. Other recent trials provide hope that newer thrombectomy devices might provide a clinical benefit by allowing faster and more-complete recanalization. For now, endovascular stroke therapy following intravenous TPA is not likely to provide additional benefit in anterior circulation occlusions. Instead, eligible patients should be enrolled in randomized trials comparing new devices with intravenous TPA.
Hooman Kamel, MD
Published in Journal Watch Neurology March 5, 2013
Based on articles published in Physician’s First Watch Feb 7 2013 and Feb 8 2013
Ciccone A et al. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013 Feb 6; [e-pub ahead of print]. [PubMed ® abstract]
Broderick JP et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013 Feb 6; [e-pub ahead of print]. [PubMed ® abstract]
Copyright © 2013. Massachusetts Medical Society. All rights reserved.
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