Literature
Clinical Pearls & Morning Reports
Published April 5, 2023
In the trial by Sarraj et al., how did thrombectomy plus medical care compare with medical care alone among patients with a large, acute ischemic stroke?
Sarraj et al. conducted a phase 3, randomized, controlled trial involving patients with a large, acute ischemic stroke that evaluated whether endovascular thrombectomy plus medical care within 24 hours after stroke onset led to better functional outcomes than medical care alone. Read the NEJM Original Article here.
Clinical Pearls
Q: Have patients with large strokes been well represented in prior thrombectomy trials?
A: Endovascular thrombectomy has been shown to be more effective in reducing disability than medical therapy alone in selected patients with ischemic stroke due to a large cerebral vessel occlusion. However, patients with large strokes on noncontrast computed tomography (CT) or perfusion imaging have been underrepresented in thrombectomy trials. Consequently, the safety and efficacy of thrombectomy in patients with a larger ischemic burden have not been well established.
Q: What are some of the tools used to measure the volume of infarcted tissue in stroke patients?
A: The estimated extent of ischemic change in acute stroke differs depending on the imaging method that is used to measure the volume of infarcted tissue. Ischemic changes on noncontrast CT appear as areas of hypodensity and are assessed with the use of the semiquantitative measure of the Alberta Stroke Program Early Computed Tomography Score. Perfusion imaging identifies quantitative brain volume with critically reduced blood flow that is considered irreversibly damaged, whereas diffusion-weighted magnetic resonance imaging detects the volume of brain tissue affected by cytotoxic edema.
Morning Report Questions
Q: How did thrombectomy plus medical care compare with medical care alone among patients with a large, acute ischemic stroke in this trial?
A: At 90 days, the median score on the modified Rankin scale was 4 (interquartile range, 3 to 6) in the thrombectomy group and 5 (interquartile range, 4 to 6) in the medical-care group. The Wilcoxon–Mann–Whitney probability of superiority was 0.60 (95% confidence interval [CI], 0.55 to 0.65), and the generalized odds ratio favoring endovascular thrombectomy was 1.51 (95% CI, 1.20 to 1.89; P<0.001). Functional independence at 90 days (a score on the modified Rankin scale of 0 to 2) was observed in 20.3% of the patients in the thrombectomy group and in 7.0% of the patients in the medical-care group (relative risk, 2.97; 95% CI, 1.60 to 5.51). Independent ambulation (a score on the modified Rankin scale of 0 to 3) at 90 days occurred in 37.9% of the patients in the thrombectomy group and in 18.7% of the patients in the medical-care group (relative risk, 2.06; 95% CI, 1.43 to 2.96). Results for the other secondary outcomes were generally supportive of those of the primary analysis. Early neurologic worsening occurred in 44 patients (24.7%) in the thrombectomy group and in 27 patients (15.5%) in the medical-care group (relative risk, 1.59; 95% CI, 1.03 to 2.45).
Q: What were some of the safety outcomes of the trial?
A: Symptomatic intracranial hemorrhage occurred in 1 patient (0.6%) in the thrombectomy group and in 2 patients (1.1%) in the medical-care group (relative risk, 0.49; 95% CI, 0.04 to 5.36). At 90 days, 68 of 177 patients (38.4%) in the thrombectomy group and 71 of 171 patients (41.5%) in the medical-care group had died (relative risk, 0.91; 95% CI, 0.71 to 1.18). Procedural complications occurred in 33 patients (18.5%) in the thrombectomy group.