A small non-randomised study, led by Ronen R Leker, Hebrew University Hadassah Medical Centre, Jerusalem, Israel, published in Stroke, indicates that in patients with proximal middle cerebral artery occlusion (pMCOA), stent-based thrombectomy may be associated with more favourable outcomes than intravenous tissue plasminogen activator (tPA).
Leker et al reported that a trial, known as IMS III (International management of stroke III), previously attempted to ascertain whether endovascular therapy may extend the therapeutic window to eight hours in stroke treatment, but they said that the trial ended before results were gathered. They added that the treatment used in this study was “outdated”, and therefore, whether endovascular therapy is superior to intravenous tissue plasminogen activator (tPA) is still unknown. Leker et al aimed to compare the outcomes of patients with proximal middle cerebral artery occlusions treated with tPA with proximal middle cerebral artery occlusion patients treated with stent-based thrombectomy.
In the study of 88 patients with pMCOA, 66 patients who presented in the first three hours of symptom onset were treated with systemic tPA and 22 patients with a National Institutes of Health Stroke Scale (NIHSS) score of ≥10 and were not eligible to receive tPA were treated with endovascular SBT. The tPA patients were diagnosed via CT scan and CT angiography (unless they had contraindications) while the SBT-treated patients were diagnosed with vascular imaging.
Despite having a higher NIHSS baseline score and longer time from symptom onset than tPA-treated patients, SBT-treated patients saw more favourable outcomes (60% vs. 37.5%; p=0.001, respectively) when compared with tPA-treated patients. Also, the patients who received SBT, despite having a similar length of hospital stay as the tPA patients, had a greater improvement in their baseline NIHSS scores. Additionally, half of SBT-treated patients had poor collaterals but recanalisation was achieved relatively rapidly and the rates of recanalisation was relatively high (recanalisation was not assessed in the tPA-treated patients).
Leker et al concluded: “The main results of the current study are that treatment with SBT may be at least as efficacious as tPA in patients with large hemispheric infarcts. We observed a shift toward better outcomes in SBT-treated patients despite having higher admission NIHSS scores,” however, they added: “Our results should be interpreted with caution and should be viewed as hypothesis-generating, prompting a randomised prospective study comparing the two treatment options.”