Time Means Brain! Fast Treatment for Acute Ischemic Stroke Improves Recovery

Diederik Dippel MD, PhD Senior Consultant in Neurology Erasmus MC University Medical Center  Rotterdam The NetherlandsMedicalResearch.com Interview with:
Diederik Dippel MD, PhD

Senior Consultant in Neurology
Erasmus MC University Medical Center
Rotterdam The Netherlands

Medical Research: What is the background for this study? What are the main findings?

Dr. Dippel: MR CLEAN is the first randomized clinical trial to show that intra-arterial treatment of ischemic stroke to get the clot out, really works. It leads to more recovery and less handicap. Previous studies had shown that intra-arterial treatment leads to recanalization, but the final proof that the treatment leads to recovery more often than standard treatment was lacking.

With standard treatment, less than 1 out of 5 recovers without handicap, but with this new treatment, this will be 1 out of 3. The treatment did not lead to more complications than standard treatment. The rate of symptomatic intracranial hemorrhage was similar in both arms.

Our study differs from previous, neutral trials.

  • First, we required patients to have an intracranial arterial occlusion confirmed by neuro-imaging.
  • Second, we used third generation thrombectomy devices, such as retrievable stents in most of the cases.
  • Third, our trial was conducted in a country with a very good infrastructure, which allowed rapid transfer to intervention centers, which are spread throughout the country. Our rate of iv tPA in Dutch hospitals is over 11% on average.
  • Last, all intervention centers participated, and almost no patients were treated outside the trial. Moreover, reimbursement of the treatment was conditional on participation in the trial.

Medical Research: What should clinicians and patients take away from your report?

Dr. Dippel: Intra-arterial treatment for acute ischemic stroke in patients with a confirmed intracranial occlusion of the anterior circulation, who can be treated within 6 hours from onset, is safe and effective. Confirmation of the occlusion should be done with MRA or CTA. Intra-arterial treatment should be started as soon as possible. Time is brain!

We were very happy that we could show that the treatment works at least as well in elderly people, even in those over 80 years. We also had proof that the treatment works in patients with what at first appears to be a mild stroke, but often turns out to be al large one if you do not treat.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Dippel: Still more studies like MR CLEAN need to be done, we would like to have our findings confirmed. We need to determine the relationship between time since onset and effect of the treatment and we certainly need to find out which additional medication, such as antiplatelet agents and anticoagulants should be given and when this should be done. There is a large gap between the chances of recanalization on the one hand, and the chance of good recovery on the other. We need to close that gap. This will require efforts in basic and in clinical research. There is a lot of work ahead of us.

Citation:

A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

Olvert A. Berkhemer, M.D., Puck S.S. Fransen, M.D., Debbie Beumer, M.D., Lucie A. van den Berg, M.D., Hester F. Lingsma, Ph.D., Albert J. Yoo, M.D., Wouter J. Schonewille, M.D., Jan Albert Vos, M.D., Ph.D., Paul J. Nederkoorn, M.D., Ph.D., Marieke J.H. Wermer, M.D., Ph.D., Marianne A.A. van Walderveen, M.D., Ph.D., Julie Staals, M.D., Ph.D., Jeannette Hofmeijer, M.D., Ph.D., Jacques A. van Oostayen, M.D., Ph.D., Geert J. Lycklama à Nijeholt, M.D., Ph.D., Jelis Boiten, M.D., Ph.D., Patrick A. Brouwer, M.D., Bart J. Emmer, M.D., Ph.D., Sebastiaan F. de Bruijn, M.D., Ph.D., Lukas C. van Dijk, M.D., L. Jaap Kappelle, M.D., Ph.D., Rob H. Lo, M.D., Ewoud J. van Dijk, M.D., Ph.D., Joost de Vries, M.D., Ph.D., Paul L.M. de Kort, M.D., Ph.D., Willem Jan J. van Rooij, M.D., Ph.D., Jan S.P. van den Berg, M.D., Ph.D., Boudewijn A.A.M. van Hasselt, M.D., Leo A.M. Aerden, M.D., Ph.D., René J. Dallinga, M.D., Marieke C. Visser, M.D., Ph.D., Joseph C.J. Bot, M.D., Ph.D., Patrick C. Vroomen, M.D., Ph.D., Omid Eshghi, M.D., Tobien H.C.M.L. Schreuder, M.D., Roel J.J. Heijboer, M.D., Koos Keizer, M.D., Ph.D., Alexander V. Tielbeek, M.D., Ph.D., Heleen M. den Hertog, M.D., Ph.D., Dick G. Gerrits, M.D., Renske M. van den Berg-Vos, M.D., Ph.D., Giorgos B. Karas, M.D., Ewout W. Steyerberg, M.D., Ph.D., H. Zwenneke Flach, M.D., Henk A. Marquering, Ph.D., Marieke E.S. Sprengers, M.D., Ph.D., Sjoerd F.M. Jenniskens, M.D., Ph.D., Ludo F.M. Beenen, M.D., René van den Berg, M.D., Ph.D., Peter J. Koudstaal, M.D., Ph.D., Wim H. van Zwam, M.D., Ph.D., Yvo B.W.E.M. Roos, M.D., Ph.D., Aad van der Lugt, M.D., Ph.D., Robert J. van Oostenbrugge, M.D., Ph.D., Charles B.L.M. Majoie, M.D., Ph.D., and Diederik W.J. Dippel, M.D., Ph.D. for the MR CLEAN Investigators

N Engl J Med 2015; 372:11-20January 1, 2015DOI: 10.1056/NEJMoa1411587

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