Patients with acute ischemic stroke who are younger, free of comorbidities that put them at risk for stroke, and successfully reperfused are more likely to have a good neurologic outcome following treatment with catheter-based therapies, according to results of a small case series published online December 4, 2014, ahead of print in Catheterization and Cardiovascular Interventions. Moreover, both periprocedural complications and short-term outcomes are similar whether patients are treated by neurointerventionalists or interventional cardiologists, suggesting the latter have a place in acute stroke care.

But in a telephone interview with TCTMD, interventional neurologist Tudor G. Jovin, MD, of the University of Pittsburg Medical Center (Pittsburgh, PA), called the study “self-serving” and mainly an attempt to justify participation of interventional cardiologists in the field.

“I’m sympathetic to a broad range of specialties doing this procedure,” he commented, but the claim, based on this limited dataset, that interventional cardiologists are qualified to perform acute stroke intervention “is a bit worrisome.”

Nay Htyte, MD, MS, of Ochsner Medical Center (New Orleans, LA), and colleagues analyzed 124 consecutive patients with acute ischemic stroke (mean age 65 years: 48% men) who underwent catheter-based therapy at their institution between 2006 and 2012. About 1 in 8 patients received IV tissue plasminogen activator prior to the procedure. Intraprocedural anticoagulation and the devices employed were at the operator’s discretion.

The mean National Institutes of Health Stroke Scale (NIHSS) score on admission was 15.0, and the mean door-to-balloon time was 4 hours, 17 minutes. Successful reperfusion, defined as postprocedural thrombolysis in cerebral infarction (TICI) flow of 2 or greater, was achieved in 81%.

Neurologic Outcome Affected by Age, Reperfusion Success

Overall, rates of in-hospital and 30-day mortality were 25% and 26%, respectively. Likelihood of a good neurologic outcome (modified Rankin Scale score ≤ 2) at 90 days—the primary endpoint—was reduced by older age, the presence of multiple comorbidities, and the failure of revascularization.

For patients under 65 years, the rate of a good neurologic outcome was 64% compared with 36% for older patients (P = .002). The same dichotomy was seen at the threshold of 80 years (55% vs 30%; P = .021). Patients with no comorbidities also fared better than those with multiple conditions that increase stroke risk (diabetes, hypertension, hyperlipidemia, and history of transient ischemic attack/stroke; 83% vs 35%; P = .014). And patients with successful reperfusion had a good neurologic outcome in 57% of cases vs 17% for those with failed procedures (P < .001).

The same patterns were seen for 30-day mortality.

Overall, 29% of patients experienced periprocedural complications, including intracranial hemorrhage during the index hospitalization in 23%. Four patients had major intraprocedural complications: 2 dissections of the intracranial arteries, 1 cerebral edema, and 1 reperfusion hemorrhage.

No Difference in Outcomes Between Cardiologists, Neurologists

Interventional cardiologists and neurointerventionalists treated roughly similar proportions of patients (46% and 53%, respectively), with no differences between the specialties in rates of the primary outcome, death during the index hospitalization, 30-day mortality, mean NIHSS score, or lesion type. A trend toward more periprocedural complications was seen in neurointerventionalist-treated patients.

Importantly, achievement of postintervention TICI ≥ 2 flow was similar between the 2 types of specialists despite a clear preference for balloon angioplasty and stents among interventional cardiologists (used in 60% of their patients) and mechanical thrombectomy with or without stenting among neurointerventionalists (used in 6% and 86% of their patients, respectively).

A Political Statement?

“This is more a political statement than a scientific manuscript,” declared Philip M. Meyers, MD, of Columbia University Medical Center (New York, NY), in a telephone interview with TCTMD. “While the authors speak to a multidisciplinary stroke team approach at Ochsner, it is surprising that only cardiologists authored this manuscript.

“We have entered the era of large multicenter randomized trials,” Dr. Meyers said, and at this point, “publication of single-center, nonrandomized, nonadjudicated data is not constructive.”

With regard to the reported complications, Dr. Jovin noted that the events were collected through retrospective chart review, “which is a problem.” Moreover, he added, “it is not clear whether a neurologist—somebody who is attuned to Rankin scores—actually scored the outcomes.” With these kinds of methodological shortcomings, “I put very little value on the accuracy of this report,” he said.

Dr. Meyers observed that interventional cardiologists preferentially employed stent-supported angioplasty in 60% of their patients despite the fact that this strategy is experimental and thus presumably was used without Institutional Review Board approval.

He noted that while training standards for neuroradiologists to perform stroke intervention have existed since 2010, traditionally interventional cardiologists have not undertaken specific acute stroke training, which involves cognitive as well as procedural skills. “Often interventional cardiologists take the view: ‘We’re universal vascular specialists—we know blood vessels and what is at the end of the vessel is less important,’” he said.

Dr. Jovin said a major issue is the very low volume of acute stroke procedures performed at Ochsner, and the lack of appreciation of the multiple dimensions of care that go into obtaining good acute stroke outcomes reflects that limited experience.

“The first thing we need to do is demonstrate the benefit of this intervention in randomized trials,” Dr. Jovin said. “Fortuitously, such data have recently become available. However, I emphasize that these trials showed benefit only when experienced, trained operators were performing the procedures.”

Even the authors’ claim of a “manpower shortage” is not clear, Dr. Jovin said, since across the country each neurologically trained operator has performed only about 10 procedures. “The problem is competing hospitals. Breaking down those interhospital barriers is a more logical way to address the shortage. The answer is not to invite in poorly trained interventional cardiologists,” he said.

A ‘Responsible’ Approach

But in an email with TCTMD, study coauthor Christopher J. White, MD, also of Ochsner Medical Center, responded that the investigators’ primary purpose was to look at factors that affected outcomes after stroke intervention, “not to ‘compare’ neurointerventionalists to cardiologists. That was simply one parameter, [which we analyzed] because it was apparent that the 2 groups had different approaches to acute strokes—stents vs thrombectomy devices—[and] it turned out not to make a difference.”

Dr. White asserted:  “[W]e at Ochsner have taken a very responsible approach to stroke intervention. We always work with a team including a stroke neurologist to provide neurologic expertise before, during, and after the intervention.

“We believe that stroke reperfusion is underutilized in the US due to the scarcity of neurointerventionalists,” Dr. White continued. “If interventional cardiologists can achieve similar outcomes with the neurologists’ help, then we can offer critical reperfusion therapy to more stroke patients. I would suggest that our approach is very patient-centered, while the criticisms of the neurointerventionalists seem to be self-centered.”

 

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Source: 
Htyte N, Parto P, Ragbir S, et al. Predictors of outcomes following catheter-based therapy for acute stroke. Catheter Cardiovasc Interv. 2014;Epub ahead of print.

Disclosures: 
Drs. Htyte, White, Jovin, and Meyers report no relevant conflicts of interest.

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