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Guideline update recommends stent-retrieval devices to treat certain patients with stroke
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The American Heart Association and American Stroke Association published a guideline update on early management of patients with acute ischemic stroke, now recommending use of a stent-retrieval device in certain patients within 6 hours of stroke onset.
“What we’ve learned in the last 8 months, from six new clinical trials, is that some people will benefit from additional treatment with a stent-retrieval device if a clot continues to obstruct one of the big vessels after [tissue plasminogen activator] is given,” William J. Powers, MD, FAHA, H. Houston Merritt distinguished professor and chair of the department of neurology at the University of North Carolina at Chapel Hill and chair of the guideline’s writing committee, said in a press release. “This additional treatment is more difficult than [tissue plasminogen activator], which can be given by most doctors in the [ED].”
William J. Powers
The document analyzes the evidence from the SYNTHESIS Expansion, IMS III, MR RESCUE, MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA and REVASCAT trials. The latter five were conducted with latest-generation stent-retriever devices and showed greater efficacy in the intervention group compared with controls than did the other trials.
Patient criteria
Patients who meet all of the following criteria should receive endovascular therapy with a stent retriever: prestroke modified Rankin scale (mRS) score of 0 or 1; acute ischemic stroke; tissue plasminogen activator (tPA) received within 4.5 hours of onset; causative occlusion of the internal carotid artery or M1 section of the proximal middle cerebral artery; age 18 years or older; NIH Stroke Scale score of 6 or higher; Alberta Stroke Program Early CT score of 6 or higher; and initiation of treatment within 6 hours of symptom onset, according to the update.
“Reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better outcomes,” the authors wrote. “To ensure benefit, reperfusion to [Thrombolysis in Cerebral Infarction] grade 2b/3 should be achieved as early as possible and within 6 hours of stroke onset.” Effectiveness of endovascular therapy after 6 hours from symptom onset is uncertain, they wrote.
Endovascular therapy with stent retrievers within 6 hours of stroke onset is reasonable in patients with anterior circulation occlusion contraindicated for IV tPA, and endovascular therapy with stent retrievers within 6 hours may be reasonable for patients with causative occlusion of the M2 or M3 section of the middle cerebral arteries, anterior cerebral arteries, vertebral arteries, basilar artery or posterior cerebral arteries, according to the document.
Such therapy within 6 hours also may be reasonable in those with causative occlusion of the internal carotid artery or M1 section of the proximal middle cerebral artery and prestroke mRS score of greater than 1, ASPECTS score of less than 6 or NIH Stroke Scale score of less than 6.
The evidence indicates that stent retrievers are preferred to the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) device (Concentric Medical), but use of mechanical thrombectomy devices other than stent retrievers may be reasonable in some cases, according to the document.
Regional systems of care
The update also includes a recommendation that patients be transported quickly to the nearest certified primary stroke center or comprehensive stroke center, and backs the development of regional systems of stroke care.
“Endovascular therapy requires the patient to be at an experienced stroke center with rapid access to cerebral angiography and qualified neurointerventionalists,” the authors wrote. “Systems should be designed, executed and monitored to emphasize expeditious assessment and treatment.”
The guideline update has been endorsed by the American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), the AANS/CNS Cerebrovascular Section, the American Society of Neuroradiology, and the Society of Vascular and Interventional Neurology, and has been affirmed as an educational tool for neurologists by the American Academy of Neurology. – by Erik Swain
Disclosure: Powers reports no relevant financial disclosures. See the full document for a list of the relevant financial disclosures of the other authors and reviewers.
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