When Pamela Nelson suffered a stroke last June, she was treated at Denver’s Swedish Medical Center by Donald Frei, MD, a neuro-interventional surgeon. Dr. Frei used endovascular therapy on Nelson, who is now fully recovered. Frei’s work is outlined in a new study published in the New England J of Medicine, which was stopped early because of overwhelming efficacy of treatment.
“This clinical trial proves beyond any doubt that inside the artery therapy is the best possible treatment for patients suffering an acute ischemic stroke from a large artery occlusion,” said Frei, who is part of the Radiology Imaging Associates at Swedish Medical Center in Englewood, CO. He is co-author of the report that confirms endovascular treatment (ET) dramatically improves patient outcomes after stroke.
“I feel I’ve fully recovered,” said Nelson, a Denver resident. “I wouldn’t be here without this treatment. Swedish is the place for stroke care.” Dr. Frei, who is also the President-Elect of the Society of Neuro Interventional Surgery with headquarters in Fairfax, VA, has been successfully treating stroke patients with “inside the artery” therapy for several years in his practice, and trusts the findings of this clinical trial. “The vast majority of our patients benefit from ET,” he said. “But the key factor is time. The patient’s best chance for an independent outcome is to get to a comprehensive stroke center as fast as possible.”
The clinical trial, known as ESCAPE (Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times) presented overwhelming evidence that ET improves patient outcomes from 29 percent to 53 percent.
ET is performed by inserting a thin tube into the artery in the groin, through the body, and into the brain vessels to the clot. This is done under image-guided care using an X-ray. The clot is then removed and pulled out, restoring blood flow to the brain.
STUDY METHODS AND OUTCOMES
In the study, patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either underwent endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or continued receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (≥8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days.
In many cases according to the report, instead of suffering major neurological disability, patients went home to resume their lives, regaining full independence. The overall mortality rate was reduced from two in 10 patients for standard of care treatment to one in 10 patients – a 50 per cent reduction with ET.
Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P=0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P=0.01).
And for more on Swedish Medical Center’s Comprehensive Stroke Center and RIA