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Ischemic Stroke: Dissolve or Retrieve

By: Dr. E. Seyman

Endovascular treatment of stroke has a distinct advantage compared with clot dissolving drugs (t-PA) when treating a large blocked vessel

A stroke occurs when blood supply to part of the brain is disturbed. This is predominantly caused by blood clots which can form in the brain or in a different region of the body from which it can migrate to the brain. Once a vein is blocked, blood supply to the adjacent areas stops and irreversible tissue damage occurs within minutes.
Cells located at the focal point of the blockage die almost immediately, while damage to peripheral cells is more limited, and can even be prevented if the patient is treated quickly in a hospital. However if the condition is left untreated, damage will spread resulting in extensive cell death.
The conventional treatment for this condition is called thrombolysis, which means breaking down the clot using a specific set of drugs called t-PA (Tissue Plasminogen Activator). T-PA is given via IV, quickly traveling through the blood stream to the brain. 
A relatively new alternative involves removing the clot using brain stenting. Through this method the physician inserts a catheter into an artery near the groin through which the clot can be reached and removed.
Leading medical facilities around the world have implemented this endovascular treatment over the past years, however a number of papers published in 2013 called into question the efficacy of this method compared with t-PA. These findings have not disqualified this treatment as an option, but have left loose ends and unanswered questions.
This year, six new studies were published which shed light on these questions and conclusively prove that in some cases, endovascular treatment does in fact have a distinct advantage over t-PA. Data showed that t-PA is extremely ineffective in treating blockages of larger brain vessels, mostly those leading to the frontal areas of the brain. Endovascular intervention, however, does successfully treat these situations. 
Besides proving a certain treatment to be effective, these studies raise an interesting question: what’s changed since 2013? Why are the current results so different to the old ones? Apparently, a number of important changes have occurred.
  1. The Technology: The latest catheters are compatible with a new stent retrieval attachment which allows for quick and whole removal of the clot. While using this technology, blood circulation was greatly improved, up to 50% more with the new catheter in comparison with tPA or first generation catheters.

  2. Time Awareness: In order for the treatment to be effective, the stent must be inserted within 90 minutes following the patient's admission. This is often colloquially called "door to groin time". Meeting this deadline requires changes to the A&E admission process and work procedures which have no yet been implemented in numerous hospitals. As time goes on, this target is met in more facilities, directly influencing study results. 

  3. Neuro Radiological Indications: Over time, doctors identified patients that would benefit most from the intervention based on their imaging and clinical condition. In order to minimize adverse events and prevent unnecessary procedures, a number of criteria have been developed. For example, a stenting procedure would not be indicated if imaging shows extensive, irreversible damage. Another required finding is that the occlusion be located within a large vessel. This too ensures that when the procedure is performed, it leads to better results. 
The two treatment modalities were compared using patients’ recovery status following three months as the key indicator. Among patients treated with tPA, only 13.5% were functioning independently 90 days following treatment. In stark contrast, 31% of patients treated with brain stenting were independent following the same amount of time with no significant increase in adverse treatment reactions. 
Dr. E. Seyman is a neurologist specialising in the treatment of stroke and a Medix consultant

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