Question:

-In acute stroke, does the addition of intra-arterial management improve outcomes compared to usual care?

Methodes: 

-Multicenter, randomized, open-label (but blinded end points) in the Netherlands. 502 patients in 16 centers.

-Comparing: (comparing intra-arterial intervention within 6 hours + usual care) vs. usual care.

-Required a radiologically proven intracranial occlusion for study eligibility

-Intervention was arterial catheterization and delivery of a thrombolytic agent, mechanical thrombectomy, or both, within 6 hours (method left up to the interventionist)

-Approx 90% in each group got TPA (considered usual care in this trial).

Results: 

-The primary outcome was distribution of modified Rankin scale at 90 days. These favored the intervention group in all categories except death.

-Regarding patient who were functionally independent with Rankin score of 0-2, the was 32.6% in the intervention group  vs. 19.1% in the control group.

Mr. Clean

 

-There were no differences in serious adverse events during 90 follow up period between groups.

-HOWEVER, there was a significant difference in the number of symptomatic new strokes in a different territory than the original stroke within 90 days in the intervention group (5.6% in intervention group vs. 0.4% control group)

-Also, some have noted that the TPA only group did very poorly in this trial compared to NINDS and IMS-3, which could make the intervention group look artificially superior.

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Now, it always comes down to, would you want this for yourself or a loved one? I’m sure you’ll want to read more to decide.

Further Reading:

Original Article:http://www.nejm.org/doi/full/10.1056/NEJMoa1411587#t=articleTop

Opinions and Summaries:

http://www.emlitofnote.com/2014/12/mr-clean-new-golden-age.html

http://stemlynsblog.org/jc-intra-arterial-treatment-stroke/

http://www.neuroicudoc.com/2014/11/the-mr-clean-trial-improved-outcomes.html

Watch the 2 minute NEJM summary video here:

http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMoa1411587&aid=NEJMoa1411587_attach_1&area=aop