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Study: Intra-Arterial Clot Removal More Effective at Treating Stroke Than Standard Medical Care

Rate of functional independence nearly twice as high with clot removal versus usual care alone

             In a new study published December 17 in the New England Journal of Medicine, researchers found that using an intra-arterial procedure to remove a stroke-causing blood clot in a large vessel supplying blood to the brain provides better outcomes than trying to dissolve the clot using a lytic (“clot-busting”) drug alone.

            The Multicenter Randomized CLinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) was a prospective, randomized study that compared intra-arterial treatment plus usual care with usual care alone, which could include tissue plasminogen activator (tPA), if indicated. Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intra-arterially within 6 hours after symptom onset.

            A total of 500 patients were enrolled at 16 medical centers in the Netherlands; 233 were assigned to receive intra-arterial treatment plus usual care and 267 received usual care alone. The patients’ mean age was 65 years (range, 23 to 96 years), and 445 patients (89.0%) were treated with intravenous alteplase (Activase, Genentech) before randomization. Retrievable stents (embolectomy) were used in 190 (81.5%) of the 233 patients assigned to intra-arterial treatment. In this procedure, the stent retriever is inserted into the patient’s femoral artery starting in the leg and is navigated to the site of the blood clot in the brain. Once the device is in place, the physician “grabs” the clot and removes it.

            The trial’s primary outcome was the modified Rankin Scale score at 90 days; this scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death).

            Of the patients receiving intra-arterial treatment plus usual care, 32.6% demonstrated functional independence (modified Rankin Score of 0 to 2), compared with 19.1% of the group given usual care alone, for an absolute difference of 13.5 percentage points. There were no significant differences in mortality or in the occurrence of symptomatic intracerebral hemorrhage.

                The authors concluded that intra-arterial treatment administered within 6 hours after stroke onset was effective and safe in patients with acute ischemic stroke caused by proximal intracranial occlusion of the anterior circulation.

                In the U.S., an estimated 125,000 individuals present at hospitals with this type of stroke each year.

            Sources: NEJM; December 17, 2014; and PR Newswire; December 17, 2014.

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