Clinical Study
Recanalisation success is associated with good clinical outcome despite advanced age and stroke severity in patients treated with the Solitaire stentriever

https://doi.org/10.1016/j.jocn.2013.05.005Get rights and content

Abstract

Intravenous recombinant tissue plasminogen activator is associated with significant recanalisation failure in the setting of large artery occlusion. Endovascular treatment by stentriever achieves improved rates of recanalisation but its impact on clinical outcomes remains unclear. We hypothesise that successful recanalisation, unattentuated by age and stroke severity, is associated with improved clinical outcomes in patients treated with the Solitaire stentriever (ev3 Endovascular, Plymouth, MN, USA). We conducted a retrospective study of 60 consecutive acute ischaemic stroke patients treated with the Solitaire stentriever. The data included demographics, vascular risk factors, ictal onset time, National Institutes of Health Stroke Scale (NIHSS) score at presentation, angiographic findings, post-procedure imaging, and clinical follow-up. Recanalisation success was defined as a thrombolysis in cerebral infarction score (TICI)  2b. Good clinical outcome was defined as a modified Rankin Scale score (mRS)  2 at 3 months. Of the 60 patients, the mean age was 64.1 (standard deviation 13.4) years and 68.3% were men. Median NIHSS score at presentation was 18 (interquartile range 14–22). Successful recanalisation (TICI  2b) was achieved in 44 patients (73.3%). Of these 44 patients, 25 patients (56.8%) achieved mRS  2 at 3 months. Multiple logistic regression showed significant association between recanalisation success and improved clinical outcome (p = 0.019). Of all patients, four (6.7%) developed symptomatic intracranial haemorrhage. Overall mortality was 28.3%. In conclusion, the Solitaire stentriever was associated with improved recanalisation rates. We showed that successful recanalisation is associated with good clinical outcomes after adjustments for age, sex and stroke severity.

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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