Intra-Arterial Treatment Highly Effective for Stroke

Researchers at Erasmus Medical Center (EMC; Rotterdam, The Netherlands) and other Dutch institutions participating in the MR CLEAN study randomly assigned 500 patients (mean age 65 years) at 16 medical centers in the Netherlands to either intra-arterial treatment plus usual care (233 patients) or usual care alone (267 patients). Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging, and that could be treated intra-arterially within six hours after symptom onset. The primary outcome was modified Rankin scale score at 90 days.

The results showed that 445 of the patients (89%) were treated with intravenous alteplase before randomization. Retrievable stents were used in 81.5% of the patients assigned to intra-arterial treatment. The researchers found an absolute difference of 13.5% in the rate of functional independence (modified Rankin score, 0–2) in favor of the intervention (32.6% versus 19.1%). There were no significant differences in mortality or in the occurrence of symptomatic intracerebral hemorrhage. The study was published on December 17, 2014, in the New England Journal of medicine (NEJM).

“Intra-arterial treatment consisted of arterial catheterization with a microcatheter to the level of occlusion and delivery of a thrombolytic agent, mechanical thrombectomy, or both,” concluded lead author Olvert Berkhemer, MD, of EMC, and colleagues. “This treatment leads to a clinically significant increase in functional independence in daily life by three months, without an increase in mortality.”

Intravenous alteplase administered within 4.5 hours after symptom onset is the only reperfusion therapy with proven efficacy in patients with acute ischemic stroke. However, well-recognized limitations of this therapy include the narrow therapeutic time window and contraindications such as recent surgery, coagulation abnormalities, and a history of intracranial hemorrhage. Moreover, intravenous alteplase appears to be less effective at opening proximal occlusions of the major intracranial arteries, which account for more than one third of cases of acute anterior-circulation stroke.

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