Endovascular therapy with stent retrievers may be a safe and effective option for acute ischemic stroke management because of large vessel occlusion, according to research published in the Journal of the American College of Cardiology: Cardiovascular Interventions.

Intravenous thrombosis is the most common treatment strategy for acute ischemic stroke (within 4.5 hours of onset of symptoms), but low recanalization rates in patients with large vessel occlusion and bleeding complications limit its effects.

Endovascular therapy through the use of retrievable stents combines high rates of flow restoration with stenting and mechanical thrombectomy without risks of in-stent restenosis caused by conventional stents.


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Investigators used data from 5 randomly assigned controlled trials, including MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT. The trials compared endovascular therapy with the use of retrievable stents against standard therapy for the prevention of acute stroke.

Each of the studies recorded history of diabetes and atrial fibrillation, 90-day modified Rankin Score, symptomatic intracranial hemorrhage, and 90-day mortality. The 5 studies included patients who underwent endovascular therapy (n=634) and patients (n=653) who underwent standard therapy.

The authors noted that their meta-analysis, “demonstrates the efficacy of endovascular treatment in improving functional outcomes and remarkable safety as demonstrated by no difference in rates of symptomatic intracranial hemorrhage compared to standard therapy.”

Functional independence among the trials was defined by a low Rankin Score between 0 and 2. The analysis of the 5 studies showed that the endovascular group had a low 90-day Rankin score frequency of 42.6%, and the standard therapy group had a frequency of 26.1%.

The frequency of intracranial bleeding was 4.2% in the endovascular therapy group and 4.3% in the standard therapy group. The total risk ratio was 1.08 (confidence interval [CI]:  0.64-1.82, P=.78).

The endovascular therapy group has a 15.1% 90-day mortality rate and the standard therapy group had an 18.7% rate.  The risk ratio was 0.81 (CI: 0.58-1.12, P=.19).

The results, similar to standard therapy, suggest functional outcomes and safety for endovascular therapy, in addition to an overall decreased 90-day mortality rate. The analysis confirms that endovascular therapy is an effective acute ischemic treatment if it is administered within 12 hours of the onset of stroke symptoms. Further advances of stent retrieval devices may also extend this window to 15 hours.

“It is anticipated to result in major changes in the health care systems and accelerate the development of centers of excellence, such as comprehensive stroke centers, that will be preferentially able to accept and treat patients with the most severe ischemic strokes,” the authors predicted.

Reference

Marmagkiolis K, Hakeem A, Cilingiroglu M, et al.  Safety and Efficacy of Stent Retriever for the Management of Acute Ischemic Stroke: Comprehensive Review and Meta-analysis. J Am Coll Cardiol. 2015. doi: 10.1016/j.jcin.2015.07.021.