AHA/ASA Updated Recommendations for Acute Stroke Treatment Include Stent Retrievers With tPA

June 29, 2015—The American Heart Association/American Stroke Association announced that for the first time, its guidelines recommend using a stent retrieval device to remove blood clots in select stroke patients who have clots obstructing the large arteries supplying blood to the brain.

Published online ahead of print in Stroke, the 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment is a guideline for healthcare professionals. William J. Powers, MD, is lead author of the focused update. Dr. Powers is H. Houston Merritt Distinguished Professor and Chair of the Department of Neurology at the University of North Carolina at Chapel Hill.

According to the AHA/ASA, the optimal initial treatment for an ischemic stroke remains intravenous delivery of tissue plasminogen activator (tPA) administered within a few hours after stroke symptoms to dissolve the clot and re-establish blood flow to the brain, limiting stroke disability.

The focused update analyzes results from randomized clinical trials published since the last treatment guidelines were issued in 2013.

In the AHA/ASA announcement, Dr. Powers commented, “What we’ve learned in the last 8 months from six new clinical trials is that some people will benefit from additional treatment with a stent retrieval device if a clot continues to obstruct one of the big vessels after tPA is given.”

The focused update recommends that stroke patients have their clots removed with a stent retriever if they: had no significant disability before the current stroke; received tPA within 4.5 hours of symptom onset; have a clot blocking a large artery supplying blood to the brain; are at least 18 years old; had an acute, severe stroke; have imaging showing that more than half of the brain on the side of the stroke is not permanently damaged; and can have the procedure start within 6 hours after symptom onset.

The focused update states that the use of stent retrievers is indicated in preference to other mechanical thrombectomy devices, but notes that the use of mechanical thrombectomy devices other than stent retrievers may be reasonable in some circumstances based on a physician’s clinical judgment.

The evidence backing this new recommendation received the highest rating based on the scientific evidence reviewed and suggests the benefits substantially outweigh the potential risks in these patients, advised the AHA/ASA.

Dr. Powers noted, “This additional treatment is more difficult than tPA, which can be given by most doctors in the emergency room.” He added, “Clot removal with a stent retriever requires a specialized center, such as Comprehensive Stroke Centers, or other healthcare facilities with specially trained people, including some Primary Stroke Centers. This treatment has to be done within 6 hours of the onset of stroke, so in some areas it can be tricky to get you to an appropriate hospital in time.”