Combining routine therapy, thrombectomy could improve outcomes in at-risk stroke patients

Combining thrombectomy with traditional medical therapies in at-risk stroke patients could yield more favorable outcomes, according to research published in the New England Journal of Medicine this February.

Endovascular thrombectomy has long been a treatment of choice for acute ischemic stroke patients with occlusion of either the first segment of the middle cerebral artery or the internal carotid artery, but until recently the procedure was limited to a six-hour window after the patient was last known to be well, lead study author Gregory W. Albers, MD, and colleagues wrote. That changed with the release of DAWN trial results, which suggested the treatment window could be expanded to up to 24 hours.

Clinicians have also seen promise for treating these patients with combined diffusion and perfusion MRIs, which can reportedly estimate the volume of irreversibly injured ischemic tissue and the volume of brain tissue that’s ischemic, but salvageable.

“These techniques may identify patients who will have a favorable response to endovascular reperfusion therapy, even when the therapy is initiated longer after the onset of stroke symptoms than is typical in clinical practice,” the authors wrote.

Albers et al. designed the DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) trial to test whether patients with remaining ischemic brain tissue that’s not yet been infarcted responded more favorably to endovascular therapy than traditional medical therapy 6 to 16 hours after they were last known to be well. Patients with salvageable brain tissue were identified with perfusion imaging, the paper stated.

The team’s study picks met specific criteria—the 182 patients who participated had either a proximal middle-cerebral-artery or internal-carotid-artery occlusion, an initial infarct size of less than 70 ml and a ratio of volume of ischemic tissue on perfusion imaging to infarct volume of 1.8 or more. Ninety-two were randomized to the endovascular therapy group, while the remaining 90 underwent routine medical therapy alone.

Albers and co-authors found that in the cohort who’d undergone endovascular therapy plus medical therapy, patients saw better functional outcomes on a modified Rankin scale after 90 days. Those same individuals were also more likely to be functionally independent.

Though there was no significant difference between groups when it came to the frequency of intracranial hemorrhage or serious adverse events, endovascular therapy patients recorded a 14 percent 90-day mortality rate, while their counterparts saw a 26 percent rate.

“Endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well, plus standard medical therapy, resulted in better functional outcomes than standard medical therapy alone among patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion,” the authors said. “Our findings confirm and extend those of the DAWN trial.”