Early thrombectomy after stroke yields better outcomes

The earlier that endovascular thrombectomy plus medical therapy can be given to a patient with an ischemic stroke, the less the patient’s disability at 3 months (when compared with medical therapy alone), according to a study in the September 27, 2016 issue of JAMA.

“The conclusions are that thrombectomy is an effective therapy, but it’s time dependent. And treatment within the first 2 to 3 hours—a short onset-to-puncture time—will dramatically improve outcomes,” explained first author Jeffrey L. Saver, MD, Professor of Neurology at the David Geffen School of Medicine at UCLA and Medical Director of the UCLA Stroke Center, in Los Angeles, CA.

For this study—the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trial (HERMES)—the researchers pooled data from 5 Phase III trials that included 1,287 acute large-vessel ischemic stroke patients on four continents. All patients were randomized to standard medical therapy (including tPA, if indicated) or to thrombectomy plus standard medical therapy (including tPA, if indicated).

“We found that time is critically important to the outcome from this treatment,” Dr. Saver said. “Benefit was seen up to 7.3 hours after onset; but within those 7 hours, every moment counted. In fact, every 6 minutes that went by after hospital arrival, 1 fewer out of 100 patients was independent 3 months after their stroke if the artery had not been opened.”

For every 1,000 stroke patients given endovascular reperfusion, a 15-minute reduction in emergency department door–to-reperfusion time would result in 39 patients having a less-disabled outcome at 3 months, researchers calculated. In addition, the less time from brain imaging to reperfusion also results in better 3-month functional outcomes.

“We need patients to get to the cath lab as fast as possible after they arrive,” Dr. Saver said. “We found evidence that a good target might be a door-to-puncture time of 75 minutes for hospitals that do this procedure.”

“These findings should drive system change for health systems and regional ambulance systems across the country and across the world,” he added. “We need to reorganize our ambulance systems to get patients who are having more severe strokes due to large-vessel occlusions to comprehensive stoke centers as fast as possible. This might involve routing select patients directly to comprehensive stroke centers to get this lifesaving therapy early.”

Dr. Saver summarized the study in this JAMA video.