HEADS UP re: NEJM editorial about 2 new randomized trials evaluating mechanical removal of certain clot-related strokes

As you may have already seen, NEJM today published the results of two prospective, randomized trials (ESCAPE-MeVO and DISTAL) that found thrombectomy – a medical procedure that involves using a specially-designed clot removal device inserted through a catheter to pull or suck out the clot and restore blood flow to the brain of a patient suffering an ischemic stroke – added no clinical benefit compared to standard medical management for medium and distal vessel occlusion strokes. This is bound to stir up lots of chatter and debate among stroke experts, many of whom are currently attending the International Stroke Conference (ISC) in Los Angeles where the study results are also being presented.

J Mocco, MD, System Vice Chair of the Department of Neurosurgery and Director of the Cerebrovascular Center at Mount Sinai and an internationally-renowned stroke expert, was asked by NEJM to pen an editorial on the two papers. He explains that “because few procedures have experienced a decade of practice-changing clinical trials as impressive at stroke thrombectomy with multiple trials demonstrating benefit for early large vessel occlusion “LVO” (the largest and most devastating form of ischemic stroke) and findings from post-other trials suggesting benefit for thrombectomy in smaller clot-related strokes that have led to thrombectomy for non-LVO strokes to become an increasingly accepted practice,” this will be big news out of ISC. Below are some key points from his editorial that are important to note if you plan to cover the trial results.  

Key Points from Dr. Mocco’s editorial:

Patient cohort: Inclusion criteria for both trials varied from prior thrombectomy studies beyond juts their vessel location/size criteria. Enrollment included patients with higher baseline disability, which may have reduced the potential benefit of thrombectomy because of the difficulty in improving a baseline disability. The trials also enrolled patients with an ~10 year median older age than previous notable studies. Furthermore, the patients had milder deficits than seen in prior trials.  These facts raise the possibility that physicians may have not enrolled many patients (those who were younger, with more severe deficits, or with better baseline function) but treated them anyways outside of the trial. 

Technical approach: ESCAPE-MeVO required stent retrievers as a first-line approach and, while DISTAL did not mandate an approach, 80% of cases utilized stent retrievers. Likewise, both trials experienced lower reperfusion rates than seen in most prior trials (ESCAPE-MeVO: 75%; DISTAL: 71.7%). It remains unclear if this is due the chosen approaches’ technical limitations, or whether physician decision-making for older, or less severe deficit, patients played a role

Bottom Line: No matter how one considers these data, there is no question they represent the current ground zero of evidence to inform medium and distal vessel occlusion thrombectomy decision making. They clearly demonstrate thrombectomy for distal occlusions should not be an assumed default care pathway.  

If you’re interested in speaking with Dr. Mocco, I’ll be glad to connect you.