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Medical Rounds

Stents on a Stick

When the U.S. Food and Drug Administration approved the use of tissue plasminogen activator (tPA) in 1996, it was a watershed moment for stroke treatment. Many ischemic stroke patients who were destined for a lifetime of extreme disability or death often went on to live productive lives. However, tPA was an imperfect fix, notes neurologist Victor Urrutia, director of The Johns Hopkins Hospital’s Stroke Center. When clots are lodged within the brain’s larger arteries or when significant time has passed, tPA isn’t as effective.

But new tools approved for use just three years ago could make the difference for patients when tPA doesn’t. These devices, known as stentrievers, mechanically remove blood clots from the brain, providing a way to reopen arteries even when stubborn clots don’t respond fully to tPA. Recent studies published in the New England Journal of Medicine showed that combining the use of stentrievers with tPA can increase the number of people living independently three months after stroke from 30 percent to nearly 70 percent.

The new devices are basically “stents on a stick” that open within a clot. By threading the collapsed chicken-wirelike stent into a clot with a wire, then opening it, these devices interdigitate the clot’s gelatinous material, allowing surgeons to easily grab it and remove even large clots buried deep within the brain. Blood flow is instantly restored, leading to less ischemic damage and, thus, better function for patients over time.

Now, any patient who receives tPA could potentially be a candidate for these other therapies if they have a large-order occlusion and don’t show signs of an already concluded stroke in imaging.

Because of the specialized nature of this therapy, it’s mostly offered at certified Comprehensive Stroke Centers, such as The Johns Hopkins Hospital. These centers, numbering around 80 in the country, have the necessary concentration of experts and tools to effectively and safely deliver this therapy. For this reason, Urrutia says, he and colleagues across the nation are leading efforts to modify routing protocols for ambulances to deliver suspected stroke patients to Comprehensive Stroke Centers, even if they have to bypass other hospitals.