Until recently, thrombolytic therapy has been the only proven treatment for acute ischaemic stroke. A recent study in the Netherlands, however, found that interventional thrombectomy improved functional outcomes in patients with emergent cranial large-vessel occlusions, even among patients who had already received tissue plasminogen activator (tPA) for thrombolytic therapy.
The American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the Joint AANS/CNS Cerebrovascular Section strongly endorse interventional thrombectomy in the treatment of acute ischaemic stroke in their article, “MR CLEAN: past the tipping point of clinical equipoise,” by Henry H Woo et al, published online, ahead of print, in the Journal of Neurosurgery.
Five hundred patients with imaging-confirmed occlusion of proximal arteries in the anterior cerebral circulation were enrolled in MR CLEAN (the multicentre randomised clinical trial of endovascular treatment for acute ischaemic stroke in the Netherlands) and treated within six hours of symptom onset. All patients were given the usual standard of care, which included prompt administration of tPA (alteplase) in 89% of patients. Approximately half of the patients also received interventional thrombectomy, which in 82% was accomplished using retrievable stents. The addition of interventional thrombectomy proved more favourable than usual care alone, with a 13.5% improvement in the absolute rate of functional independence between the two treatment groups. The results of MR CLEAN were reported in the New England Journal of Medicine.
Woo and colleagues describe differences between MR CLEAN and three previous studies that were unable to prove the advantages of interventional thrombectomy for acute ischaemic stroke. The earlier studies suffered from lack of imaging confirmation of large-vessel occlusion, use of antiquated interventional technologies, and insufficient statistical power. The authors applaud the achievements of MR CLEAN.
Speaking to the future, Woo and colleagues point out that work still needs to be done to improve patients’ lives following ischaemic stroke. The authors call on neurosurgeons and all health care professions to improve patient care by identifying and triaging patients with emergent large-vessel occlusion with greater accuracy and speed. They point out that these lesions may be more time sensitive than acute myocardial infarction, and first responders and the public should be trained to respond quickly and efficiently.