The effect of age on outcome after intra-arterial treatment in acute ischemic stroke: a MR CLEAN pretrial study

My God, they aren't even considering that this treatment does nothing to stop the neuronal cascade of death. Any conclusion they make has no basis.
http://www.ncbi.nlm.nih.gov/pubmed/27185043

Beumer D^1,2, Rozeman AD³, Lycklama À Nijeholt GJ⁴, Brouwer PA⁵, Jenniskens SF⁶, Algra A^7,8, Boiten J³, Schonewille W⁹, van Oostenbrugge RJ¹⁰, Dippel DW¹¹, van Zwam WH¹²; MR CLEAN Pretrial Investigators.

Author information

Abstract

BACKGROUND:

In recent randomized controlled trials (RCTs) intra-arterial treatment (IAT) has been proven effective and safe for patients with acute ischemic stroke (AIS). So far, there seemed to be no interaction between older age (>80) and main treatment effect. We studied the association of older age with outcome and adverse events after IAT in a cohort of intra arterially treated patients.

METHODS AND FINDINGS:

Data from all AIS patients with proven proximal anterior circulation cerebral artery occlusion who were intra arterially treated between 2002 until the start of the MR CLEAN trial were studied retrospectively. Duration of the procedure, recanalization (Thrombolysis In Cerebral Infarction score (TICI)), early neurological recovery (i.e. decrease on NIHSS of ≥ 8 points) after one week or at discharge, good functional outcome at discharge by modified Rankin Scale (mRS ≤ 2) and the occurrence of neurological and non-neurological adverse events were assessed and the association with age was investigated. In total 315 patients met our inclusion criteria. Median age was 63 years (range 22-93) and 17 patients (5.4 %) were over 80. Age was inversely associated with good functional outcome (adjusted Odds Ratio (aOR) 0.80, 95 % CI: 0.66-0.98) for every 10 years increase of age. Age was not associated with longer duration of the procedure, lower recanalization rate or less early neurological recovery. The risk of all adverse events (aOR 1.27; 95 % CI: 1.08-1.50) and non-neurological adverse events (aOR 1.34; 95 % CI: 1.11-1.61) increased, but that of peri-procedural adverse events (aOR 0.79; 95 % CI: 0.66-0.94) decreased with age.

CONCLUSION:

Higher age is inversely associated with good functional outcome after IAT in patients with AIS. However, treatment related adverse events are not related to age. These findings may help decision making when considering treatment of older patients with AIS.

Should the severity of ischemic stroke affect your choice of treatment?

In a nutshell neither tPA nor mechanically removing it addresses the neuronal cascade of death. They aren't even asking the right question. The question is: 'What group of actions results in the least amount of dead and damaged neurons?'
http://medivizhat or.com/blog/SampleLibrary/stroke/should-the-severity-of-ischemic-stroke-affect-your-choice-of-treatment/

In a nutshell

This study looked at patients with ischemic stroke and investigated whether removing blood clots via a flexible tube inserted into the artery is only beneficial and safe for patients with less severe strokes. 

Some background

A stroke is a disruption of blood flow to an area in the brain. It can be caused by a blood clot (ischemic stroke) or a ruptured blood vessel (hemorrhagic stroke).
The loss of oxygen supply can result in cell death and brain damage. Immediate treatment is therefore necessary in order to restore blood and oxygen flow.
Treatment for an ischemic stroke can involve intra-arterial therapy. This is where a flexible tube (catheter) is inserted into a blood vessel and moved along the blood system until it reaches the blocked artery. The blood clot is then broken down by releasing drugs (thrombolytic drugs) into the artery or by mechanically removing it via the tube.
However, it is not known whether this approach is only effective in patients with less severe strokes. A type of brain scan, called noncontrast computed tomography (NCCT) is used to determine the size of the brain area that has been deprived of oxygen (called infarcts). A scale of 0-10 determines the size of the affected area, with lower scores having larger infarct areas and greater damage. 

Methods & findings

This study investigated whether intra-arterial treatment is only effective and safe in treating ischemic stroke in patients with an NCCT score of >5 (less severe stroke).
The study included 249 patients with ischemic stroke. All patients underwent an NCCT scan and were divided into 3 groups: 0-4 (large infarcts), 5-7, and 8-10 (smaller infarcts). All patients underwent intra-arterial treatment with thrombolytic drugs.
The study found that patients with higher scores (>5) benefited more from intra-arterial therapy and had higher rates of good outcome (better recovery) and lower rates of mortality, compared to those with lower scores. Rates of good outcome were 5% in the 0-4 group, 38.6% in the 5-7 group, and 46% in the 8-10 group. Mortality rates were 55% in the 0-4 group, 28.9% in the 5-7 group, and 19% in the 8-10 group.
A side effect of intra-arterial therapy is a brain hemorrhage, or brain bleed. The study found that brain hemorrhages were more common among patients with lower scores. It was also found that early treatment resulted in better outcomes only among patients with higher scores.

The bottom line

The study concluded that ischemic stroke patients should receive NCCT scans to determine infarct size and suggest that patients with large infarcts should not receive intra-arterial treatment as it is unlikely to improve patient outcome and increases the risk of hemorrhage.

The fine print

The study only included patients who had a stroke caused by a blood clot in the anterior cerebral artery. 

What’s next?

If you or someone you know are at risk of having a stroke, talk to a doctor about the benfits and risks of intra-arterial therapy and whether treatment should be determined by infarct size. (Yeah, while mostly either non-communicative or unresponsive YOU are supposed to be directing your emergency room doctor into how to treat you. Any more stupid ideas?)

UTHealth professor awarded $1 million grant from Stryker Neurovascular for stroke research

This researcher is going down the wrong route. You don't need to select the right patients, you need to figure out why all the patients don't recover better. There is a simple answer. The neuronal cascade of death has not been addressed at all. Fix that and your therapy will work much better. This is what happens when you don't have a stroke strategy that is being followed. The scattershot approach rarely works. The mentors for this guy do not know enough to be mentors. This is why stroke survivors need to be in charge.
http://www.news-medical.net/news/20150506/UTHealth-professor-awarded-241-million-grant-from-Stryker-Neurovascular-for-stroke-research.aspx

A $1 million grant for stroke research has been awarded from Stryker Neurovascular to Amrou Sarraj, M.D., assistant professor of neurology at The University of Texas Health Science Center at Houston (UTHealth).
Sarraj completed his residency and fellowship at UTHealth, where he began investigating which patients would do best with intra-arterial therapy - the mechanical removal of a blood clot that has stopped blood flow in an artery in the brain, during which a catheter is deployed through an artery in the groin up to the site of the clot.
While still a fellow, Sarraj devised a new scoring method to help physicians determine if a patient is a candidate for intra-arterial therapy. Called the Houston Intra-Arterial Therapy 2 "HIAT2" score, the new method earned him the Mordecai Y.T. Globus New Investigator Award in Stroke from the American Stroke Association (ASA) in 2012.
The dilemma for neurologists is that while intra-arterial therapy re-opens a clogged artery in 80 percent of patients, ONLY 30 PERCENT have an improved outcome.
"Even if you open the vessel, there can be too much damage that has already occurred,"(Wrong. You haven't stopped the damage that continues to occur in the death cascade) said Sarraj, who is an attending physician at Memorial Hermann-Texas Medical Center and Mischer Neuroscience Institute at Memorial Hermann. "We need to be able to select the right patients."(Wrong, wrong, wrong. Determine why your patients don't all recover, your assumption is wrong.)
At the recent ASA International Stroke Conference, Sarraj presented new study findings that revealed blood circulation flow, the extent of damage and patient age may be more important than arrival time when physicians are predicting which patients would benefit the most from intra-arterial therapy.
The new grant will fund a multi-institutional study that will evaluate different selection methods currently being used to see which one has the greatest probability of selecting the patients most likely to benefit from intra-arterial therapy. There are potential health care cost savings, he said, by avoiding an unnecessary procedure. The new study is called Optimizing Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT).

"This project has become all the more important as new published studies are beginning to show benefit of endovascular therapy for acute stroke," said Sean I. Savitz, M.D., professor of neurology and director of the UTHealth Stroke Program and Memorial Hermann-Texas Medical Center Stroke Center. "This grant represents the culmination of several years of research that Amrou has been doing. We are very proud of him."
"Now that endovascular therapy is a proven treatment, future trials should assess strategies to enhance clinical outcomes and optimization of patient selection and SELECT will take the lead," Sarraj said. "Informing stroke patients' families on their chances of having good outcomes after intra-arterial therapy is crucial; we hope the study will bring an answer to that".
Sarraj credits mentors including Savitz; Andrew Barreto, M.D., associate professor of neurology; Jon E. Tyson, M.D., M.P.H., professor of pediatrics and director of the Center for Clinical Research and Evidence-Based Medicine; Kathleen A. Kennedy, M.D., M.P.H., the Richard W. Mithoff Professor of Pediatrics and director of the MS Clinical Research Degree Program; and Charles Green, Ph.D., associate professor at the Center for Clinical Research and Evidence-Based Medicine. Sarraj is a graduate of the masters' degree research program.
"I would also like to thank Mark Paul and Mark O'Brien for their vision," Sarraj said. Paul is the president of the Neurovascular Division of Stryker Neurovascular while O'Brien is vice-president of Customer Excellence.

Source:

University of Texas Health Science Center at Houston