Paradigm shift for acute stroke therapy

Paradigm shift for acute stroke therapy

Three international trials have proven the benefits of an acute stroke ‘clot retrieval’ therapy that has been carried out at Auckland City Hospital for the last three years.

At the International Stroke Conference in Nashville this week, three new treatment trials (including one with patients from New Zealand), reported results showing clear benefit for ‘clot retrieval’ compared with other available stroke treatment.

The principal investigators of the New Zealand arm of the ‘EXTEND IA’ trial were neurologist Professor Alan Barber from the University of Auckland, and interventional neuroradiologist Dr Ben McGuinness from Auckland City Hospital.

“In all the years that I’ve been coming to this meeting I have never been to a session where three positive stroke trials have been presented,” says Professor Barber who was in Nashville for the presentation.

“We’ve been performing clot retrieval therapy at Auckland City Hospital for the past three years. It is complex and requires intensive resources with a lot of co-operation between the emergency department, neurology, interventional neuroradiology, anesthetic and intensive care teams.”

“But the results can be dramatic as confirmed in these new studies,” he says. “It’s good to have a treatment that has the potential to make a difference to people coming into hospital with the devastating effects of stroke.”

Stroke is the third most common cause of death after heart disease and all cancers combined and affects around 8,000 New Zealanders every year. Many of the survivors are left dependent on others to carry out basic activities of daily living.

Most strokes are due to a clot that forms in the heart or that breaks off from atherosclerotic plaques in the carotid arteries in the neck. The clot then floats downstream before getting stuck in one of the arteries supplying blood to the brain. The brain supplied by this blocked artery stops working and will die unless the clot breaks down within a few hours.

“The current main treatment consists of giving a clot-busting drug (‘tPA) into a vein,” says Professor Barber. “This is moderately effective with a third of people receiving this treatment being more likely to recover enough to go home independently.”

The three trials presented at the conference were the EXTEND IA trial from Australia and New Zealand, the ESCAPE trial from Canada and Europe (both published in the New England Journal of Medicine to coincide with the meeting) and the SWIFT PRIME study from the United States.

“All independently found significant benefit from ‘clot retrieval’,” he says.

Clot retrieval involves inserting a catheter into an artery in a patient’s groin, moving this up into the brain and ‘retrieving’ the clot – literally pulling it out of the circulation. This restores blood flow to the brain immediately and limits any further permanent damage.

Professor Barber says that in all three studies, patients had standard treatment with tPA given in the veins but then half had clot retrieval as well.

“Those with clot retrieval were much more likely to recover their independence so that for every three to four patients treated (depending on which of the three studies you look at), one patient was able to go home and look after him or herself independently.”

“Furthermore, clot retrieval didn’t result in any more serious adverse events,” says Professor Barber. “These three studies follow a Dutch study that showed the same benefit of clot retrieval reported late last year.”

“It’s going to take some time to reorganise the way we do things in our hospitals, but this treatment represents a paradigm shift in the way we will treat stroke patients,” he says.

ENDS

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