Stroke update recommends use of stent retrievers

The American Heart Association (AHA) and the American Stroke Association (ASA) added the use of stent retrieval devices for treating some patients with acute ischemic stroke in updated guidelines published online June 29. The gold standard remains intravenous tissue plasminogen activator (tPA) for breaking up clots.

The AHA and ASA revisited their guidelines to include recent clinical trials that evaluated the safety and effectiveness of endovascular therapy with stent retrievers. Some of the results had been unveiled at the 2015 International Stroke Conference’s scientific sessions in Nashville, Tenn.

In EXTEND-IA (Extending the Time for Thrombolysis in Emergency Neurological Deficits), for instance, researchers reported that promptly performing thrombectomy with a stent retriever in carefully selected ischemic stroke patients led to better outcomes than did alteplase treatment alone. Mean reperfusion at 24 hours totaled 100 percent with endovascular therapy vs. 37 percent with alteplase alone; the thrombectomy group also had higher rates of early neurological improvement at three days and improved functional outcomes.

The ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times) trial found that 53 percent of patients who received standard care plus rapid endovascular treatment had a modified Rankin score of two or less at 90 days compared to 29.3 percent for patients who received standard care alone. The intervention group also had a lower 90-day mortality rate, at 10.4 percent vs. 19 percent.

“What we’ve learned in the last eight months, from six new clinical trials, is that some people will benefit from additional treatment with a stent retrieval device if a clot continues to obstruct one of the big vessels after tPA is given,” William J. Powers, MD, lead author of the update, said in a news release. He is chair of the neurology department at the University of North Carolina at Chapel Hill.

The update writers noted that the usefulness of mechanical thrombectomy devices other than stent retrievers has yet to be established. Most of the patients in ESCAPE and one other trial they reviewed were treated with stent retrievers, and all of the patients in EXTEND-IA and two other trials that informed the update treated patients with stent retrievers.

They determined that based on the randomized trials, the recommendations for stent retrievers in select patients was Class I, Level of Evidence A. They reiterated that patients who were eligible for tPA should receive the medication even if they are to be treated with stent retrievers as well.

The recommendations, which update 2013 guidelines, were published in Stroke.