Clinical StudyRecanalisation success is associated with good clinical outcome despite advanced age and stroke severity in patients treated with the Solitaire stentriever
Introduction
The use of intravenous recombinant tissue plasminogen activator (IV-rtPA) improves outcomes for acute ischaemic stroke. This was shown in a study by the National Institute of Neurological Disorders and Stroke1 when thrombolysis was administered within 3 hours and further studies showed sustained benefit up to 4.5 hours.2, 3, 4 It is on this basis that intravenous thrombolysis is offered as first line treatment for acute ischaemic stroke patients.
Rapid recanalisation appears to be the key to good clinical outcomes in acute stroke. However, recent studies showed poor recanalisation rates post IV-rtPA (46.2%)5 with consequent poor outcomes.6, 7, 8, 9 Of note, occlusion of the distal internal carotid artery and proximal middle cerebral artery respond poorly to IV-rtPA.10, 11, 12, 13
The recent development of devices for mechanical clot retrieval offer improved recanalisation rates of up to 69.5% for the MERCI device (Concentric Medical, Mountain View, CA, USA)14 81.6% for Penumbra (Penumbra, Alameda, CA, USA)15 and 89.7–100% for the most recent Solitaire stentriever (ev3 Endovascular, Plymouth, MN, USA).16, 17 There is emerging interest in the provision of mechanical clot retrieval as first line therapy or adjunct therapy to IV-rtPA.18 However, recent findings by investigators of Interventional Management of Stroke III,19 SYNTHESIS Expansion20 and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE)21 showed equivalent clinical outcomes comparing intra-arterial (IA) therapy with IV-rtPA alone. There was reasonable concern that these studies employed an older generation of IA strategies (such as the MERCI device) leading to lower recanalisation rates and consequent poorer clinical outcomes.
We hypothesise that, in patients with similar age and stroke severity, successful recanalisation (thrombolysis in cerebral infarction [TICI] score ⩾ 2b) by Solitaire stentriever is associated with improved clinical outcomes. We report here our single centre experience with the Solitaire stentriever in 60 patients.
Section snippets
Data extraction
This study received approval from the Ethics Committee at our institution. Patients who underwent mechanical clot retrieval with the Solitaire stentriever were extracted from a prospectively maintained stroke database. Patient demographics, vascular risk factors (hypercholesterolaemia, diabetes, hypertension, atrial fibrillation and smoking), stroke symptom onset time, the National Institutes of Health Stroke Scale (NIHSS) score at presentation and modes of treatment were obtained from the
Results
From December 2009 to August 2012, 60 consecutive patients (41 men and 19 women) with a mean age of 64.13 (SD 13.41) years were treated with the Solitaire stentriever at The Royal Melbourne Hospital. NIHSS scores at presentation were available in all patients and the median NIHSS score was 18 (IQR 14–22; range, 2–35). Cardiovascular risk factors included diabetes (21.7%), hypertension (48.3%), hypercholesterolaemia (40.0%), smoking (28.3%) and atrial fibrillation (41.7%). These baseline patient
Discussion
We found that successful recanalisation (TICI ⩾ 2b) was associated with improved outcomes in a population of patients treated with the Solitaire stentriever, independent of age, sex, stroke severity and procedure duration, with an OR of 33.3 (95% CI 2.14–518.6; p = 0.012). Mortality following successful recanalisation was also lower with an OR of 0.14 (95% CI 0.019–0.985; p = 0.048). The Solitaire stentriever achieved a high rate of recanalisation (73.3%) with a low rate of symptomatic haemorrhage
Conclusion
In conclusion, we showed a high rate of successful recanalisation using the Solitaire stentriever in acute ischaemic strokes. Recanalisation is a significant determinant of functional outcome, unattenuated by age, sex and stroke severity. However, data from randomised controlled studies are required to definitively demonstrate clinical benefit prior to recommending its general application to acute ischaemic stroke.
Conflicts of Interest/Disclosures
The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
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