Study Supports Use of 'Brain Stents' for Certain Stroke Patients
Certain stroke patients might benefit from angioplasty and the placement of artery-opening stents in brain blood vessels, a new study suggests.
The finding focuses on ischemic strokes—attacks that occur when blood flow in the brain in blocked, often by a blood clot or fatty deposit. In brain angioplasty, a balloon-tipped catheter is guided to the area of the blockage and the balloon is inflated in order to open the blocked blood vessel. Once the balloon is deflated and withdrawn, a tiny mesh tube called a stent is inserted to help the vessel remain open.
This study included 131 ischemic stroke patients, averaging about 66 years of age, in the Czech Republic. All had suffered a middle cerebral artery blockage. Seventy-five of the patients received a clot-busting drug while the rest were not eligible for such drugs, which must be given within four-and-a-half hours of stroke onset and cannot be given to patients taking blood-thinning drugs.
Due to these types of limitations, many ischemic stroke patients receive no treatment at all, said researcher Dr. Martin Roubec, a neurologist at the University Hospital Ostrava in the Czech Republic, and colleagues.
Of the patients in the study who received a clot-busting drug, 35% had a favorable outcome three months after their stroke. Among the patients in which the clot-busting drug failed to re-open the blocked artery, just less than one-half underwent brain angioplasty/stent replacement while the rest received no additional treatment.
Of the patients who underwent angioplasty/stenting, nearly one-half had a favorable three-month outcome, compared with just 15% of the patients who received no further treatment.
Among the patients who did not receive a clot-busting drug, 31 underwent angioplasty/stenting and 25 received no further treatment. Favorable outcomes were reported in 45% of those who underwent angioplasty/stenting and in 8% of those who received no further treatment.
The study was published online Dec. 11 in the journal Radiology.
For patients with this type of arterial blockage who cannot receive clot-busting drugs or do not benefit from them, re-opening the vessel "with stents is superior to providing no further therapy," Roubec said in a journal press release.
Two experts in the United States stressed that the usefulness of this approach is still being debated.
Dr. Keith Siller is medical director of the Comprehensive Stroke Care Center at NYU Langone Medical Center in New York City. He noted that although the Czech trial found a real benefit for patients with ischemic stroke, another trial (known by the acronym SAMMPRIS), "concluded that patients with recent stroke and [mini-strokes] from longstanding blockages in brain arteries had worse outcomes with angioplasty and stenting compared to using standard medications (aspirin, clopidogrel, statin) combined with aggressive risk-factor modification (exercise, diet, etc.)."
However, Siller—who is also assistant professor at the NYU School of Medicine—said the Czech trial used similar stents but focused on "a slightly different" and less easily managed subset of patients who "are known to have the worst outcomes if their arteries remain blocked."
He believes that for these patients, "Roubec's report clearly shows that in experienced hands, angioplasty and stenting led to better clinical outcomes and less hemorrhagic complications with results that were superior to the patients in SAMMPRIS."
The bottom line, for Siller: Angioplasty plus stenting may have a role for these worst-case patients, but the approach is "still unproven in less urgent scenarios where the goal is preventing recurrence in the near future."
Another expert agreed.
"Based on the study, stenting in the acute stroke setting may be an option for patients that have contraindications for [clot-busting drugs]," said Dr. Rafael Ortiz, director of the Center for Stroke and Neuro-Endovascular Surgery at Lenox Hill Hospital in New York City. "Further prospective information about stenting in the acute stroke setting is necessary to make final recommendations about the safety and efficacy of this therapy."