Intra-arterial Stroke Treatment
Mechanical thrombectomy
All trials looked at patients with occlusion of ICA or M1
Only 94 M2 occlusion patients included in the trials no indication that they do worse (but not statistically significant)
Summary of Trials
HERMES paper meta-analysis of all previous RCTs
From practical neurology 2017:
MR CLEAN Study
NEJM
2014
500pts
in Netherlands (all stoke centres in the country participated)
Inclusion:
All
patients with proximal occlusion and NIHSS at least 2
Included
patients with contraindication to IV TPA
Randomized
to usual care vs usual care +IA therapy
IA
therapy could include IA TPA or mechanical removal
Mechanical
removal technique was at local discretion; ~80% was with stent-retriever
Median
NIHSS 17-18
Results:
mRS 0-2 (functionally independent) at 90days
o
32.6% vs 19.1%
o
ARR 13.5% (NNT 7.4)
o
OR 2.16
5.6%
of intervention patient vs 0.4% of control patients had a stroke in another
vascular territory within 90days
Discussion:
Probably
succeeded because unlike the previous 2 negative trials:
o
It recruited all eligible patients in the
country (unlike in USA where it was the leftovers)
o
It required a proximal occlusion to be
demonstrated
o
Modern stent retriever was used for the
majority
Many
patients in intervention group also had ICA stenosis stented at the same time
which may have contributed to increased recurrent stroke rate.
Prolonged time frame trials of mechanical thrombectomy
DAWN trial
NEJM 2018
USA based
~100 patients in each arm
Inclusion:
o Occlussion of intracranial ICA or M1
o Time of onset 6-24 hours
o Premorbid MRS 0-1
o Group A
- Age >80
- NIHSS >10
- Core <21ml
o Group B
- Age <80
- NIHSS >10
- Core <31ml
o Group C
- Age <80
- NIHSS >20
- Core 31-51ml
Software - RAPID
Patient characteristics
o Av Age ~70
o NIHSS median 17
o Treated with TPA 5v13%
o Core median 7.6 v 8.9ml
o Onset time median ~12hours
Outcomes
o Functional independence 90 days - 49 vs 13%
o Infarct core at 24 hours 8 vs 22 ml
No major difference in subgroups
Safety
o No difference in death rates
o ICH at 24 hours 6% vs 3%
o Procedural complications 7%
DEFUSE trial
NEJM 2018
USA based
~90 patients in each arm
Software RAPID
o Ischaemia = Tmax >6 sec
Inclusion
o 6-16 hours after last seen well
o Occlusion of cervical or intracranial ICA or proximal MCA
o Core <70ml
o Ratio penumbra/core > 1.8
o Penumbra >15ml
Patient characteristics
o Age median 70yrs
o NIHSS 16
o TPA ~10%
o Median core ~10ml
o Median penumbra 115ml
o Time onset to randomisation - ~11hours
Outcomes
o mRS at 90 days 3 vs 4
o Functional independence at 90 days 41% vs 15%
o Trend to reduced death 14% vs 26%
o ICH 9% vs 3%
