Endovascular Thrombectomy plus Medical Therapy shows better results in Stroke: JAMA Study

In an analysis that included nearly 1,300 patients with large vessel ischemic stroke, earlier treatment with endovascular thrombectomy (intra-arterial use of a micro-catheter or other device to remove a blood clot) plus medical therapy (use of a clot dissolving agent) compared with medical therapy alone was associated with less disability at 3 months, according to a study appearing in the issue of JAMA.

Five randomized trials have demonstrated the benefit of second generation endovascular recanalization therapies over medical therapy alone among patients with acute ischemic stroke due to large vessel occlusions (blockage). However, uncertainties remain about the benefit and risk of endovascular intervention when under taken more than 6 hours after symptom onset. Michael D. Hill, M.D., M.Sc., of the University of Calgary, Calgary, Canada, and colleagues conducted a meta-analysis of the data from these 5 randomized trials (1,287 patients enrolled at 89 international sites). Demographic, clinical, and brain imaging data as well as functional and radiologic outcomes were pooled.

The researchers found that compared with medical therapy alone, earlier treatment with endovascular thrombectomy plus medical therapy was associated with lower degrees of disability at 3 months. Benefit was greatest with time from symptom onset to arterial puncture for thrombectomy of less than 2 hours and became nonsignificant after 7.3 hours.

Among 390 patients who achieved substantial reperfusion with endovascular thrombectomy, each 1-hour delay to reperfusion was associated with a less favorable degree of disability and less functional independence, but no change in mortality.

The authors note that within 7.3 hours, “functional outcomes were better the sooner after symptom onset that endovascular reperfusion was achieved, emphasizing the importance of programs to enhance patient awareness, out of hospital care, and in-hospital management to shorten symptom onset-to-treatment times.”

“The results of this study reinforce guideline recommendations to pursue endovascular treatment when arterial puncture can be initiated within 6 hours of symptom onset, and provide evidence that potentially supports strengthening of recommendations for treatment from 6 through 7.3 hours after symptom onset.”

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Jeffrey L. Saver, Mayank Goyal, Aad van der Lugt, Bijoy K. Menon, Charles B. L. M. Majoie, Diederik W. Dippel, Bruce C. Campbell, Raul G. Nogueira, Andrew M. Demchuk, Alejandro Tomasello, Pere Cardona, Thomas G. Devlin, Donald F. Frei, Richard du Mesnil de Rochemont, Olvert A. Berkhemer, Tudor G. Jovin, Adnan H. Siddiqui, Wim H. van Zwam, Stephen M. Davis, Carlos Castaño, Biggya L. Sapkota, Puck S. Fransen, Carlos Molina, Robert J. van Oostenbrugge, Ángel Chamorro, Hester Lingsma, Frank L. Silver, Geoffrey A. Donnan, Ashfaq Shuaib, Scott Brown, Bruce Stouch, Peter J. Mitchell, Antoni Davalos, Yvo B. W. E. M. Roos, Michael D. Hill. Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis. JAMA, 2016; 316 (12): 1279 DOI: 10.1001/jama.2016.13647