NEW YORK (Reuters Health) - Stent-retriever therapy for the treatment of acute ischemic stroke improves the rate of functional independence at 90 days, according to a systematic
review and meta-analysis.
Stent retrievers are deployed in an occluded vessel, temporarily expanded into the body of a thrombus, and then retracted along with the thrombus.
Dr. Mark J. Eisenberg, from Jewish General Hospital/McGill University, Montreal, Quebec, Canada, and colleagues compared stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) versus rtPA alone for the treatment of acute ischemic stroke in their systematic review and meta-analysis of five randomized controlled trials (RCTs) with a total of 1,287 patients.
In all five trials, patients randomized to stent-retriever therapy had significantly better functional independence (a modified Rankin Scale (mRS) score of 0-2) at 90 days than did patients randomized to rtPA alone.
Stent-retriever therapy also doubled the likelihood of a one-unit improvement in mRS score at 90 days, according to the January 25 JAMA Neurology online report.
In pooled analyses, there were no significant differences between treatment groups in all-cause mortality, intracranial hemorrhage, or parenchymal hematoma rates at 90 days.
The number needed to treat to achieve an mRS score of 0 to 2 at 90 days was six.
"Given the totality of the evidence regarding the benefits and risks of stent retrievers, our results suggest that the use of these devices in patients with acute ischemic stroke is warranted," the researchers conclude.
Dr. Raphael A. Carandang, from the University of Massachusetts Medical School, Worcester, who wrote an editorial related to this report, told Reuters Health by email, "The data from these five RCTs (as the meta-analysis confirms) provides level 1 class A evidence that in the properly selected patients, stent retriever treatment is superior to the current standard of care with intravenous rtPA and would endorse that it should be considered in all acute ischemic stroke patients that are eligible for it. As with any therapy, proper patient selection is needed, but I do think it changes the landscape of acute stroke treatment going forward. I think that systems of care should be organized in stroke centers around this new therapy."
"The current technology for acute stroke care has reached the point where effective interventional therapies are clearly and unequivocally beneficial in the properly selected patients, but the key takeaway is still that the patients need to be selected properly, and the biggest factor continues to be time to recanalization, which means that all practitioners and systems of care need to focus on getting patients to treatment sooner than ever before," Dr. Carandang concluded.
Dr. Woong Yoon, from Chonnam National University Hospital, Gwangju, Korea, recently found no improvement in outcomes with stent-retriever therapy for patients with acute anterior circulation stroke (http://bit.ly/1OT7M5I). He told Reuters Health by email, "Not all patients with acute ischemic stroke can benefit from this new treatment. Patients with acute stroke due to occlusions of intracranial large vessels such as internal carotid artery, middle cerebral artery, or basilar artery and who presented within six-eight hours of stroke onset can benefit from thrombectomy with stent retrievers."
"We should realize that we are facing the moment of change in the paradigm for acute stroke treatment," Dr. Yoon concluded."Further refinement in the patient selection for stent retrieverthrombectomy is needed in the near future."
Dr. Mayank Goyal, from the University of Calgary, Alberta, Canada, coauthored two of the studies included in the current review. He told Reuters Health by email," There are several additional data coming out on this issue in the near future, which will in fact be more powerful than what is mentioned in this study."
Dr. Goyal said, "However, the key issues going into the future are: how should those patients who were not included in the current trials be treated; how should we as a collective evaluate new devices/technologies; and how do societies/countries who cannot afford stent retrievers implement endovascular stroke treatment."
Dr. Eisenberg was unavailable for comment.
The authors reported no funding. Three coauthors reported disclosures.