Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Professor and Chairman, Department of Neurology, Weill Cornell Medical College, and Neurologist-in-Chief, New York Presbyterian Hospital
Surgical Decompression for Large Ischemic Strokes
May Have Long-Term Benefit
Source: Geurts M, et al. Surgical decompression for space-occupying cerebral infarction. Outcomes at 3 years in the randomized HAMLET trial. Stroke 2013;44:2506-2508.
In a pooled analysis of three european randomized trials of hemicraniectomy for large hemispheric infarctions (Lancet Neurology 2009;8:326) within 48 hours, there was a dramatic improvement in survival at 1 year. However, this large reduction in case fatality came at the risk of severe disability in the survivors. The HAMLET investigators (Netherlands) followed up their patients at 3 years to assess functional outcome and quality of life. Poor outcome was defined as a modified Rankin Scale > 3.
Of 64 patients, 32 were randomized to surgery and 32 to best medical treatment. Just as reported at 1 year, at 3 years, surgery had no effect on the risk of poor functional outcome, but it reduced case fatality (absolute risk reduction, 37%; 95% confidence interval, 14-60). Sixteen surgical patients and eight medical controls lived at home (relative risk = 27%), and quality of life improved between 1 and 3 years in the surgical group. In conclusion, the survival benefits and disability noted at 1 year were sustained at 3 years.
New Devices for Mechanical Thrombectomy Show Promise
Source: Pereira VM, et al. Prospective, multicenter, single arm study of mechanical thrombectomy using solitaire flow restoration in acute ischemic stroke. Stroke 2013;44:2802-2807.
In the may 2012 issue of neurology alert, we reviewed three published studies of intracranial thrombectomy (New Engl J Med, 2012) for acute ischemic stroke, and noted that there was no benefit compared to intravenous thrombolysis alone. However, these studies were performed with the first generation of thrombectomy devices, and the expectation was always that newer devices would show better results. Now, investigators using one of the newer devices, a stent-retriever named "Solitaire," have reported on their results in 202 patients with anterior circulation ischemic strokes treated within 8 hours of symptom onset. The primary endpoint was revascularization of the occluded artery, and the secondary endpoint was the rate of good functional outcome (defined as Rankin Scale 0-2 at 90 days).
The median age of the patients was 72 years, and 60% were females. The median NIH Stroke Scale was 17. Intracranial occlusions occurred at the internal carotid artery in 18% and middle cerebral artery in 82%. Successful revascularization was achieved in 79.2% of patients and procedure-related adverse events occurred in 7.4%. Favorable neurological outcomes were found in 57.9% and mortality was 6.9%. Symptomatic intracranial hemorrhage occurred in 1.5%. Although this was a single-arm study without a control group, the results are highly suggestive of a dramatic benefit from use of this device, and a randomized, controlled trial is needed to confirm these results.
