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New guidelines suggest use of clot-grabbing device in some strokes

New guidelines issued Monday for the treatment of strokes recommend that doctors use a device that can grab and remove blood clots, along with a clot-dissolving drug, when certain people suffer life-threatening blockages of blood to their brains.

A “stent retriever” can be inserted into a major artery in the groin and threaded up into the large vessels that deliver blood to the head and brain. The wire mesh of the stent is pushed into the clot and expanded so that it grabs the clot, allowing the physician to pull out the blockage, which often is only the size of a pencil eraser.

The new guidelines were issued by the American Heart Association/American Stroke Association after six studies showed the device’s effectiveness.

The clot-dissolving drug – tissue plasminogen activator, or tPA – is currently the best treatment for blockages of blood vessels to the brain. But some clots are simply too large for the drug to dissolve, said William Powers, chairman of the Neurology Department at the University of North Carolina School of Medicine and chairman of the group that wrote the new guidelines. In those cases, the stent retriever, in concert with the drug, is often more effective, according to the results of various trials.

However, the guidelines recommend that the device be used only when a patient can be treated within six hours of the onset of stroke symptoms, has received tPA within 4.5 hours of experiencing those symptoms, has clots in certain areas of the large arteries that feed the brain and has a certain level of function before the procedure begins. The procedure should be performed only at comprehensive stroke centers, which are able to provide the most sophisticated stroke care.

While tPA, a blood thinner, can cause bleeding from blood vessels, the stent retriever has risks of its own. Infections can occur at the site where the artery is punctured to insert the device and damage to the blocked artery can occur, causing bleeding into the brain, according to the new recommendations.

Koto Ishida, medical director of the NYU Langone Comprehensive Stroke Care Center, who was not involved in formulating the new guidelines, said she “absolutely” supports the recommendations, which are not binding on medical centers that perform stroke intervention.

“I do believe at this point that we have multiple patently positive trial results that, at this point, are hard to refute,” she said. Stent retrievers have been in use for several years, Ishida said, but the latest generation is proving most effective at removing clots.

Nearly 800,000 Americans suffer strokes each year and 130,000 die of them, making the condition the fifth-most common cause of death in the United States, according to the website of the U.S. Centers for Disease Control and Prevention. By far the most common are “ischemic strokes,” which occur when a clot blocks blood flow to the brain. Symptoms include drooping or numbness on one side of the face, weakness or numbness in one arm and difficulty speaking.

African Americans are almost twice as likely to have strokes as whites and more likely to die after one, according to the CDC. Women are more likely to have them than men.

In any stroke, time to treatment is critical. With each passing minute, the blockage of blood is killing brain cells, leading to long-term disability or death.

In fact, according to a 2014 study, only 3 percent to 5 percent of the people who suffer strokes receive tPA, largely because they don’t arrive at hospital emergency rooms within 4.5 hours of the onset of symptoms, the window of time when the drug is effective.



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