Interventional Stroke Treatment, Results Dissapointing

Stroke

Some USA stroke facts

At least 600,000 people suffer a stroke each year.
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Stroke is the third leading cause of death (160,000 deaths annually).
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Stroke is the leading cause of disability
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Almost one third of all stroke survivors require admission to a long-term care facility.
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The annual cost of stroke-related care is estimated at over $51 billion.
Image 1 in Holland-TREC
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“Clot buster” drugs for stroke

Recombinant tissue plasminogen activator, the only FDA approved treatment for acute ischemic stroke, administered intravenously within 3 hrs of the onset of stroke symptoms, improves long term neurological outcome.
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Stroke patients treated within this time window are 30% more likely to have little or no neurological deficit 3 months after their stroke than untreated patients.  Looked at another way, for every 100 TPA patients 32 improve and 13 return to normal.
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Unfortunately, that still leaves many stroke patients with disabling neurological deficits.  Also, even though most centers now extend that time window to 4.5 hours for selected patients, many still present too late to receive TPA.
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Obviously, researchers are constantly looking for better and more widely applicable acute stroke therapies.
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A single dose of IV TPA costs about $2500, and is available all primary stroke center hospitals.
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The chances of a good outcome are highest when the drug is given within the first 90m after the onset of stroke symptoms, “Time is Brain”.
time is brain
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Endovascular therapy for stroke

Some stroke patient have a brain artery too blocked with blood clot to improve after a dose of iv TPA, and yet some or all of the affected brain tissue may still be viable, and could they improve if that artery was unblocked by some other means.
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This is the concept behind mechanical clot retrieval devices, such as the MERCI device.

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Clot retrieval devices have been shown to re-canalize blocked arteries, and are approved by the FDA for this purpose (not for improving outcome).
Example of blood clot removed from stroke patient using the MERCI  device

Example of blood clot removed from stroke patient using the MERCI device

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There are many anecdotal reports of patients who have dramatically improved after undergoing this treatment.
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A single treatment costs about $27000, requires a $2,000,000 angiography suite, and is available only at more limited comprehensive stroke centers.
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However, there have been no rigorous studies comparing clot retrieval devices to conventional treatment (iv TPA) or no treatment at all, in other words this form of treatment has been adopted into mainstream stroke care without any proof that it really improves outcome.
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Finally, some outcome data

Results from recent studies comparing iv TPA with mechanical clot retrieval were released last week at the International Stroke Conference in Hawaii.

Long term neurological outcome was the same for both groups.

That doesn’t mean we don’t still need clot retrieval for some carefully selected stroke patients.  There are some stroke patients who are not eligible for iv TPA because of recent surgery or other bleeding risk who could still benefit from clot retrieval.  Clot retrieval may still be an option for some stroke patients who present between 3-4.5 and 6 hours after the onset of their symptoms

However, conventional treatment with iv TPA  is just as good as mechanical clot removal for most stroke patients, is more readily available (primary vs comprehensive stroke centers) at much lower cost ($2,500 vs. $27,000).

This also underscores the critical importance of stroke prevention, and the need for TIA rapid evaluation centers to achieve this goal.

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