Three Studies Indicate Thrombectomy Offers No Clear Benefits for Acute Ischemic Stroke Patients

Endovascular Therapy Does Not Improve Functional Outcomes and Risks Harm Among Certain Strokes

New findings from three major randomized trials indicate that thrombectomy, a surgical procedure to remove blood clots in the brain, does not improve outcomes for patients with acute ischemic strokes resulting from blockages in medium or distal vessels. The research, presented at the International Stroke Conference, challenges prior assumptions about the procedure’s effectiveness in treating smaller strokes.

Key Findings from DISTAL, ESCAPE-MeVO, and DISCOUNT Trials

The DISTAL, ESCAPE-MeVO, and DISCOUNT trials evaluated the impact of adding endovascular therapy to best medical treatment or standard care. Results showed that functional outcomes at 90 days remained unchanged, regardless of the treatment approach. Moreover, the risk of mortality and symptomatic intracranial hemorrhage were either similar or higher in the thrombectomy groups.

“The rest of these people with these smaller strokes remained severely disabled or died, and this is not as good as we would have expected,” explained Dr. Urs Fischer from the University Hospital Bern, Switzerland. “We need, in the future, new therapies in order to improve the outcome of these patients.”

Contrast with Large Vessel Occlusions

The effectiveness of thrombectomy differs significantly when treating strokes caused by large-vessel occlusions (LVOs). In these cases, mechanical clot removal has demonstrated improved functional outcomes, even for severe and late-presenting strokes. However, the current studies dispute the idea that the procedure offers similar benefits for smaller, distal vessel occlusions.

High-Quality Evidence Sheds Light on Current Practices

According to an editorial in the New England Journal of Medicine, authored by Dr. J Mocco from the Icahn School of Medicine, these studies underscore the need to critically reevaluate current practices. The data indicate that thrombectomy should not be the default treatment for distal-vessel occlusions.

DISTAL Trial Details

The DISTAL trial included 543 patients, primarily elderly with moderate baseline disability, who had an acute ischemic stroke caused by isolated medium or distal vessel occlusions. Participants were randomized to receive either endovascular therapy alongside best medical treatment or medical treatment alone.

Results indicated no significant difference in disability levels between the two groups at 90 days. Additionally, there were no benefits seen in various subgroups. The thrombectomy group experienced higher rates of mortality and symptomatic intracranial hemorrhage.

ESCAPE-MeVO Trial Results

The ESCAPE-MeVO study was conducted across multiple countries and involved 530 patients with acute ischemic stroke from medium-vessel occlusions and favorable imaging findings. The trial examined outcomes for those receiving thrombectomy plus usual care versus usual care alone.

Neither the primary nor secondary endpoints favored thrombectomy. Safety outcomes, including 90-day mortality and symptomatic intracranial hemorrhage, were worse in the thrombectomy group.

DISCOUNT Trial Insights

The DISCOUNT trial focused on 163 patients with acute ischemic stroke involving distal vessel occlusions. Interim results showed that thrombectomy did not improve functional outcomes. The thrombectomy group had a higher risk of adverse events and intracranial bleeding.

Based on these results, the trial’s data and safety monitoring board recommended stopping the study. The analysis for the full patient population is ongoing.

The Future of Stroke Treatment

Dr. Fischer emphasized the need for new therapeutic approaches to improve outcomes for patients with medium and distal vessel strokes. Dr. Psychogios suggested that current tools may not be effective for these cases, indicating a need for better devices and methodologies.

Dr. Mocco concluded by highlighting the necessity of further high-quality research to evaluate alternative treatment options, whether procedural or medical, for medium and distal vessel occlusions.

Takeaway: A Cautionary Note on Thrombectomy for Smaller Strokes

While thrombectomy remains a crucial treatment for major strokes, these studies caution against its routine use for smaller, distal vessel occlusions. Healthcare providers must consider the evidence and carefully select patients for endovascular therapy.

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