Multiple Therapies for Acute Stroke Equals Better Outcome

Background
A number of methods are available to ensure that the highest amount of brain tissue is saved in patients with acute ischemic strokes. The first method is venous tissue-type plasminogen activator (tPA) administration, which can be done only within three hours of onset.

The next method is intraarterial thrombolysis, which must be started within six hours of symptom onset. The last method is mechanical clot removal, which can be used within eight hours of symptom onset. Angioplasty and stent placement can be used to open up stenotic vessels.

The objective of a recent study was to evaluate the safety and effectiveness of intraarterial stroke therapy for patients with acute ischemic stroke.

In patients with acute ischemic stroke, intraarterial stroke management includes angioplasty, stent placement, thrombolytic administration, and mechanical thrombectomy.

Design
This was a retrospective review of the records of patients treated intraarterially for stroke over the course of three years. The patients had a non-contrast CT, and then were evaluated with the National Institutes of Health Stroke Score (ranging from 0 to 42). The score was retabulated 7 to 10 days after treatment or at discharge.

Methodology
The patients went first for a diagnostic cerebral angiogram. If thrombolysis was contraindicated, clot retrieval was attempted. If it was feasible, heparin was given and thrombolysis was started. If initial thrombolysis failed, then clot retrieval was attempted before eight hours from onset of symptoms.

Post-angiography, the results were scored from 0 to 4 (Thrombolysis in Cerebral Infarction score). A non-contrast CT of the head was performed after 24 hours, or if the patient became symptomatic, to evaluate for bleeding. The patients were followed up by telephone interview with a modified Rankin Scale.

Results
Complete follow-up was obtained in 83 patients. Sixty-three percent of patients were given thrombolysis without thrombectomy, 17% had a combination of thrombolysis and thrombectomy, 3.6% had thrombectomy alone, and 17% had a combination of thrombolysis, thrombectomy, angioplasty, and/or stent placement. The overall recanalization rate was 76%. The median stroke severity score in the beginning was 17. The median 7- to 10-day discharge score was 5. The 90-day mortality rate was 22%. Symptomatic intracranial hemorrhage was seen in only 6% of all patients.

Conclusions/Reviewer’s Comments
This review showed favorable outcomes when combination therapies were used compared to previously published trials. The outcome of a stroke severity score of ≤2 was 11% to 12% higher than those trials. Recanalization rates were 10% higher than the thrombolysis-only studies, and 33% higher than the thrombectomy device alone. The 90-day mortality rate was slightly higher or similar to that of studies with thrombolysis alone, and lower than the study with thrombectomy alone.

The symptomatic intracranial hemorrhage rate was similar to rates of other trials in which thrombolysis was used. Despite all the limitations of this retrospective study, the use of a combination of intravascular therapies is feasible and beneficial, leading to improved cerebral perfusion and improvement in patient function, with a decrease in morbidity and mortality, all without a significant increase in morbidity or mortality compared to trials assessing single therapies.

Author: Sharon Gonzales, MD

Reference
Belisle JG, McCollom VE, et al. Intraarterial Therapy for Acute Ischemic Strokes. J Vasc Interv Radiol; 2009;20 (March): 327-333