Follow-up finds clot-grabbing devices offer better stroke outcomes
Long-term follow-up of patients in a 2014 study confirms that stroke patients recover better if doctors physically remove a clot from a blocked artery instead of just letting the clot-busting drug tPA try to do the job.
The conclusion is based on 500 Dutch patients treated in a landmark study known as MR CLEAN. The findings, reported in the New England Journal of Medicine, may encourage more hospitals to adopt the technique.
In earlier results from the study, one third of patients whose treatment included using a device to extract a clot from a brain artery achieved functional independence by the 90-day mark after their strokes compared to 19 percent given usual care.
Now, two years of data show functional independence for 37 percent of patients with clot removal versus 24 percent with clot-busting drugs alone.
"We are delighted. It is icing on the cake," said Dr Reza Jahan of the University of California at Los Angeles Stroke Center, who was not connected with the study. "It confirms the long-term durability" of the technique and it will encourage more centers to use it, he said.
The MR CLEAN study, combined with subsequent positive results released soon afterward, "has made a huge difference" in how doctors treat strokes said study coauthor Yvo Roos, a neurologist at the Academic Medical Center in Amsterdam. "This is now standard care," he told Reuters Health in a telephone interview.
Figuring out which hospitals offer the therapy can be difficult for consumers, however. There is no easy to find list of US facilities, known as comprehensive stroke centers, that are certified to offer the treatment whenever needed.
Jahan said the new study results reinforce efforts to evaluate stroke patients before they even reach a hospital and then immediately get them to one of these comprehensive stroke centers if they are candidates for clot removal.
"It will get these patients to the treatment they need faster, rather than the current model, where they may go to a primary stroke center to get clot-busting drugs and valuable time is lost trying to transport them to a comprehensive stroke center," he said by phone.
The findings apply to patients whose strokes were the result of a blockage in the large forward arteries of the brain, which is the most common type of stroke and affects up to 125,000 patients in the US and 90,000 in Europe each year.
Typically, the clot-busting drugs only open the blocked artery in about a third of the cases, which is why doctors have hoped that removing the clot directly would produce better recovery.
Clot removal is expensive - $57,031 for the extraction and for the first 90 days of other stroke treatment, according to an analysis published in December in the journal Stroke. Treatment without clot extraction cost $44,752.
With the results showing a long-term benefit with extraction, "this up-front expense is going to be justified because, in the long term, we'll see a reduction in medical care, nursing care, home care and rehabilitation care," Jahan predicted. "We're saving money in the long run. Patients who would have been stuck in a skilled nursing facility for two years, hopefully, are now being sent home."
Quality of life scores at two years were higher in the clot-removal treatment group, with the big differences reported in the categories of mobility, self-care and the ability to do usual activities.
The cumulative rates of death from any cause were comparable in the two groups during the two years after a stroke, at 26 percent among clot removal patients and 31 percent among those who didn’t get that treatment.
But Roos and his colleagues note that the difference in mortality rates has grown as time passed.