Thrombectomy for Stroke in a Cardiology Department: Preliminary Study Explores the Possibilities

ROME, Italy—The performance of catheter-based thrombectomy for acute ischemic stroke in a cardiology department by an interventional neuroradiologist and specially trained cardiologists may be a feasible option in parts of the world lacking facilities dedicated to delivering the effective intervention, a small pilot study suggests. The results, however, should be considered hypothesis-generating.

Of patients who received thrombectomy with or without prior IV thrombolytics, 41% had neurologic recovery—a modified Rankin Scale (mRS) score of 0 to 2—at 90 days, Petr Widimsky, MD, PhD (Charles University, Prague, Czech Republic), reported at the European Society of Cardiology Congress 2016.

Though that rate is lower than the average rate achieved in recent randomized trials performed at expert neuroradiology centers (48%), it is higher than the rate seen in patients who received medical therapy alone (30%), Widimsky noted in a press release.

“Acute stroke intervention done in close cooperation of cardiologists, neurologists, and radiologists is feasible and safe,” Widimsky said at a press conference. “Direct catheter-based thrombectomy [without thrombolysis] may be similarly effective and safe as bridging thrombolysis and may thus be considered in patients with contraindications for thrombolytics or in patients with very short CT-to-groin puncture times.”

He acknowledged, however, that a randomized trial is needed to confirm that idea.

“This is preliminary data,” Widimsky told TCTMD. “This is data stimulating discussion and stimulating further trials.”

A Controversial Idea

Despite an inauspicious start, endovascular therapy—primarily with stent retrievers—cemented its place in acute stroke treatment after the findings of several randomized trials in the past few years demonstrated improvements in functional outcomes for patients with large-vessel occlusions when performed following the administration of IV thrombolysis, resulting in a change to the guidelines.

Some questions remain, however, including whether performing thrombectomy without IV thrombolysis is safe and effective and whether the procedure can be completed with excellent outcomes in an interventional cardiology department when a dedicated interventional neuroradiology department is not available.

The idea of taking acute stroke intervention into the cardiology realm has proven controversial, and physicians in the stroke community are generally resistant to ceding responsibility to interventional cardiologists.

But particularly in parts of Europe, there are areas that do not have the interventional neuroradiology expertise to fully handle the demand for the catheter-based thrombectomy, Widimsky said, noting that there is now an ongoing worldwide discussion about who should be able to perform it and how training should be handled.

Intervention Possible in a Cardiology Department

To provide preliminary data to inform that debate, Widimsky and colleagues evaluated data from the PRAGUE-16 registry on 103 patients with acute ischemic stroke caused by an occlusion in a major cerebral artery who were treated at their center, which does not have a dedicated interventional neuroradiology unit. However, an interventional neuroradiologist joined their group in 2012 and trained two cardiologists to perform thrombectomy.

Based on clinical status and a CT scan, the attending neurologist determined whether patients would undergo direct thrombectomy without first receiving IV thrombolysis or IV thrombolysis followed by thrombectomy. Ultimately, 73 patients did not receive thrombolytic therapy before the procedure. Most of the procedures were performed by the interventional neuroradiologist, although the cardiologists have been taking on a greater proportion of the cases over time, Widimsky said.

The rate of neurologic recovery was roughly 40% in both groups overall, and it was higher for patients with occlusions in the middle cerebral artery instead of in the posterior circulation (59% vs 25%).

Symptomatic intracranial hemorrhage occurred in 12% of patients who did not receive IV thrombolytics and 10% of those who did, with rates of procedure-related complications of 10% and 17%, respectively.

Widimsky stressed, however, that the patients in the two groups are not comparable because of the way they were allocated to one approach or the other.

Commenting on the study at a press conference, ESC spokesperson Christian Gerdes, MD, PhD (Aarhus University Hospital, Denmark), said that “one of the key messages here is that . . . it’s possible to do these kinds of interventions in the same settings as we already know from acute myocardial infarction” and that it is feasible and safe.

But he agreed with Widimsky that the findings should be confirmed by larger studies.

Source:

• Widimsky P. Feasibility and safety of direct catheter-based thrombectomy in the treatment of acute ischemic stroke: prospective registry PRAGUE-16. Presented at: European Society of Cardiology Congress 2016. August 27, 2016. Rome, Italy.

Disclosures:

• Administrative costs for the study were covered by the Charles University Cardiovascular Research Program P35.
• Widimsky reports no relevant conflicts of interest.  

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