UMEM Educational Pearls

Treating ischemic strokes with interventional therapies (e.g., clot retrievers, stents, intra-arterial tPA, etc.) is nothing new, but there has never been a randomized control trial demonstrating benefit until recently.

The prospective MR CLEAN trial evaluated whether interventional therapies (i.e., either mechanical intervention or intra-arterial tPA) would confer benefit; patients were included if there was an acute occlusion within the proximal intracranial portion of the anterior cerebral circulation.

90% of patients received alteplase prior to randomization; there were 233 patients in the intervention group (alteplase + intraarterial intervention) and 267 patients in the usual care care arm (alteplase only); all patients were treated within 6 hours of symptoms onset

The primary outcome was functional independence at 90 days; an absolute difference of 13.5 percentage points favoring the intervention group was found. There were no significant differences in mortality or symptomatic intracerebral hemorrhage.

Despite these exciting results, we must pause and ask why this was this the first randomized trial demonstrating benefit when previous trials could not? Here are three blogs posts that deep dive this question and raise even more questions: