Stent Retrievers for the Treatment of Acute Ischemic Stroke

Abstract

IMPORTANCE Stent retrievers are a promising alternative for the treatment of acute ischemic stroke (AIS). Several recently completed clinical trials have examined the use of stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) compared with rtPA alone. OBJECTIVE To conduct a systematic review and meta-analysis of randomized clinical trials to quantify the benefits and risks of using stent retrievers in addition to rtPA for the treatment of AIS. DATA SOURCES The MEDLINE, EMBASE, and Cochrane Library of Clinical Trials databases were searched from inception to July 2015 for the keywords stent*, retriev*, Solitaire, Trevo, Revive, and stroke. Trial registries were also searched. A total of 326 publications were identified and 213 potentially relevant records were screened. STUDY SELECTION Randomized clinical trials that examined stent retrievers with rtPA vs rtPA alone were included in the meta-analysis. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted study data and performed quality assessment using the Cochrane Risk of Bias Tool. DerSimonian and Laird random-effects models were used to estimate relative risks (RRs), risk differences (RDs), and numbers needed to treat. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients achieving functional independence (defined as a score of 0-2 on the modified Rankin Scale, with 0 indicating no disability and 6 indicating death) at 90 days. Risks of all-cause mortality, intracranial hemorrhage, and parenchymal hematoma at 90 days were also assessed. RESULTS Five randomized clinical trials met our inclusion criteria (n = 1287 patients). Patients randomized to stent-retriever therapy with rtPA had significantly improved rates of functional independence at 90 days compared with those randomized to rtPA alone (RR, 1.72; 95% CI, 1.48-1.99; RD, 0.19; 95% CI, 0.13-0.25). When data were pooled across trials, the effect of stent-retriever therapy on all-cause mortality at 90 days was inconclusive (RR, 0.82; 95% CI, 0.60-1.11; RD, −0.04; 95% CI, −0.08 to 0.1). There were similarly no detectable differences in the risks of intracranial hemorrhage (RR, 1.15; 95% CI, 0.67-1.97; RD, 0.00; 95% CI, −0.02 to 0.03) or parenchymal hematoma (RR, 1.18; 95% CI, 0.71-1.94; RD, 0.01; 95% CI, −0.01 to 0.04), although the 95% CIs were wide. Fixed-effects sensitivity analyses produced similar results for all outcomes. CONCLUSIONS AND RELEVANCE The use of stent retrievers in conjunction with rtPA vs rtPA alone is associated with significant improvement of functional independence 90 days after AIS.

MRI-Based Neuroanatomical Predictors of Dysphagia, Dysarthria, and Aphasia in Patients with First Acute Ischemic Stroke

“…Without measures for early detection, dysphagia may be less salient symptomatically than dysarthria and aphasia, thereby compromising timely medical interventions such as alternatives to oral medication [12] and increasing the risk of aspiration pneumonia [13]. Also, given the potential risks of thrombolytic or endovascular therapy for patients with acute ischemic stroke [14], it is important to be able to predict major post-stroke impairments based on initial imaging and clinical and demographic factors. Knowing the key factors associated with the presence of 1 or multiple debilitating impairments may facilitate decision-making for medical interventions where potential benefits outweigh risks.…”

Improving the Clinical Outcome in Stroke Patients Receiving Thrombolytic or Endovascular Treatment in Korea: from the SECRET Study

“…Currently, the stentriever is the most commonly preferred device in approximately 90% of hospitals in Korea [8]. Stentriever use had some advantages such as easy handling, faster and complete reperfusion, temporal opening, and lesser bleeding complications [28,29]. There were increasing trends in successful recanalization (up to 87% in 2017) and rapid recanalization (mean intervals from door to final recanalization from 240.1 min in 2014 to 173 min in 2017) and decreasing trends in symptomatic intracranial hemorrhage, which might be related with growing use of stentriever over time in Korea.…”

A Direct Aspiration First Pass Technique for Mechanical Thrombectomy in the Setting of a Suspected Cerebral Aneurysm

“…A recent meta-analysis of acute ischemic stroke treatment showed that patients randomized to stent retriever therapy with IV-rtPA had significantly improved rates of functional independence at 90 days compared with those randomized to IV-rtPA alone [ 6 ]. Additionally, the introduction of ADAPT dramatically improved the efficacy of aspiration thrombectomy, as it utilizes a flexible and atraumatic large-bore aspiration catheter that can access the intracranial vasculature and provide a large cross-sectional area for thrombus aspiration without having to completely traverse the occlusion [ 4 ].…”