Neurocritical Care

, 6:11

The merci retrieval system for acute stroke

The southeast regional stroke center experience
  • T. G. Devlin
  • B. W. Baxter
  • T. A. Feintuch
  • N. A. Desbiens
Original Article

Abstract

Introduction

The Merci Retrieval System® was cleared for use in patients with stroke in August 2004. However, there are few published results of “real world experience” with the device.

Methods

We captured single-center data on 25 consecutive patients with acute ischemic stroke treated with the Merci Retrieval System according to the MERCI trial except that we treated some patients with tandem proximal carotid and intracranial lesions with carotid angioplasty and stenting and some patients were treated within the 3-hour window.

Results

Median patient age was 63 years and median initial National Institute of Health Stroke Scale (NIHSS) score was 18. Isolated M1 or M2 middle cerebral artery lesions occurred in 52% “carotid T” lesions in 8%, and vertebrobasilar lesions in 8% Tandem lesions involving proximal carotid and proximal intracranial vessel occurred in 32%, necessitating emergent multilevel treatment including carotid stenting. Median duration from symptom onset to Merci device utilization was 5.2 hours. Successful reperfusion (≥thrombolysis in myocardial infarction [TIMI] 2 flow) in the target vessel was obtained in 56% of cases. Statistical analysis revealed a strong correlation between ability to achieve greater than or equal to TIMI 2 flow a good clinical outcome as measured by 3-month NIHSS score, modified Rankin Scale (mRS), and mortality (nine out of the 12 without successful reperfusion died compared to none of the 13 with ≥TIMI 2 flow, p<0.001). Younger age and lower NIHSS score on presentation were also predictors of good clinical outcome at 3 months.

Conclusion

These “real world data” demonstrate that the results of the previous MERCI trial can be “independently replicated” at a regional stroke center. Although the results of placebo-controlled trials are still pending, mechanical revascularization has become a critical component of our acute stroke protocol, particularly for severe strokes. Issues still remain regarding recalcitrant lesions and operator experience, which necessitate further clinical testing and device optimization.

Key words

The Merci Retrieval System thrombectomy acute ischemic stroke mechanical revascularization prospective analysis recanalization 

References

  1. 1.
    The National Institute of Neurological Disorders and Stroke t-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581–1587.CrossRefGoogle Scholar
  2. 2.
    Tanne D, Bates VE, Vero P, et al. Initial clinical experience with IV tissue plasminogen activator for acute ischemic stroke: a multicenter survey. The t-PA Stroke Survey Group. Neurology 1999;53:424–427.Google Scholar
  3. 3.
    Nilasena DS, Kresowik TE, Wilburn RT, et al. Assessing patterns of t-PA use in acute stroke. Stroke 2002;33:354.Google Scholar
  4. 4.
    Clark WM, Wissman S, Albers GW, et al. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial: Atleplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Strokes. JAMA 1999;282:2018–2026.CrossRefGoogle Scholar
  5. 5.
    Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase or acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism JAMA 1999;282:2003–2011.CrossRefPubMedGoogle Scholar
  6. 6.
    IMS trial investigators. Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the interventional management of stroke study. Stroke 2004;35:904–911.CrossRefGoogle Scholar
  7. 7.
    Schneck MJ, Biller J. New treatments in acute ischemic stroke. Curr Treat Options Neurol 2005;7:499–511.CrossRefPubMedGoogle Scholar
  8. 8.
    US Food and Drug Administration. FDA Neurological Devices Panel Fifteenth Meeting. Available at: http://wwwfda.gov/ohrms/ dockets/ac/05/minutes/2004-4083m1_summary%20minutes.doc. Accessed November 6, 2006.Google Scholar
  9. 9.
    Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005;36:1432–1438.CrossRefPubMedGoogle Scholar
  10. 10.
    Smith WS. The results of the Multi MERCI trial. Stroke 2006;37:711–712.Google Scholar
  11. 11.
    National Institutes of Health. Clinical Trials. Protocol Number: NCT0094588. Available at: http://www.clinicaltrials.gov/ct/ show/NCT00094588?order=1.Accessed November 6, 2006.Google Scholar
  12. 12.
    Broderick J. The IMS III trial: a comparison of a combined IV/IA approach to recanalization with standard IV rtPA within 3 hours of onset. International Stroke Conference 2006, Feb 17, 2006. Kissimmee, FL.Google Scholar
  13. 13.
    Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: the European Cooperative Acute Stroke Study (ECASS). JAMA 1995;274:1017–1025. Abstract.CrossRefPubMedGoogle Scholar
  14. 14.
    Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind phacebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet 1998; 352:1245–1251.CrossRefPubMedGoogle Scholar
  15. 15.
    Damjanoy I, Linder J, eds. Anderson’s Pathology, 10th Edition. St. Louis: Mosby, 1996, pp. 477–483.Google Scholar
  16. 16.
    Qureshi AI, Huston AD, Harbaugh RE, Stieg PE, Hopkins LN; North American Trial of Unruptured and Ruptured Aneurysms Planning Committee. Methods and design considerations for randomized clinical trials evaluating surgical or endovascular treatments for cerebrovascular diseases. Neurosurgery 2004;54:248–264.CrossRefPubMedGoogle Scholar
  17. 17.
    Brandt T, von Kummer R, Muller-Kuppers M, Hacke W. Thrombolytic therapy of acute basilar artery occlusion: variables affecting recanalization and outcome. Stroke 1996;27:875–881.PubMedGoogle Scholar
  18. 18.
    Hacke W, Zeumer H, Ferbert A, Bruckmann H, del Zoppo GJ. Intra-arterial thrombolytic therapy improves outcome, in patients with acute vertebrobasilar occlusive disease. Stroke 1998;19:1216–1222.Google Scholar
  19. 19.
    Molina C: Degree of arterial recanalization: an endopoint for efficacy in future intravenous thrombolytic trials. Stroke 2004;35:114.CrossRefPubMedGoogle Scholar
  20. 20.
    Molina C, Montaner J, Abilleira S, et al. Speed of intracranial clot lysis with intravenous tissue plasminogen activator therapy: sonographic classification and short-term improvement. Circulation 2001;103:2897.Google Scholar
  21. 22.
    Felberg R, Okon N, El-Mitwalli A, et al. Early dramatic recovery during intravenous tissue plasminogen activator infusion: clinical pattern and outcome in acute middle cerebral artery stroke. Stroke 2002;33:1301.CrossRefPubMedGoogle Scholar
  22. 23.
    Parsons M, Barber P, Chalk J, et al. Diffusion and perfusion-weighted MRI response to thrombolysis in stroke. Ann Neurol 2005;51:28CrossRefGoogle Scholar
  23. 24.
    Wolpert S, Bruckmann H, Greenlee R, et al. Neuroradiologic evaluation of patidnts with acute stroke treated with recombinant tissue plasminogen activator. AJNR 1993;42:976–982Google Scholar
  24. 25.
    Yamaguchi T, Hayakawa T, Kiuchi H, For the Japanese Thrombolysis Study Group. Intravenous tissue plasminogen activator ameliorates the outcome of hyperacute embolic stroke. Cerebrovasc Dis 1993;3:269–272.CrossRefGoogle Scholar
  25. 26.
    Mori E, Yoneda Y, Tabuchi M, et al. Intravenous recombinant tissue plasminogen activator in acute carotid artery territory stroke. Neurology 1992;42:976–982.PubMedGoogle Scholar
  26. 27.
    Lewandwoski CA, Frankel M, Tomsick TA, et al. Combined intravenous and intra-arterial r-tPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke 1999;30(12):2598–2605.Google Scholar
  27. 28.
    Clinical highlights from the NINDS t-PA Stroke Trial. San Francisco (CA): Genentech, Inc., 1997, p. 27. Report No.:G71121-RO LB03.Google Scholar
  28. 29.
    Dunn EJ, Philippou H, Ariens RA, Grant PJ. Molecular mechanisms involved in the resistance of fibrin to clot lysis by plasmin in subjects with type 2 diabetes mellitus. Diabetologia 2006; 49(5):1071–1080.CrossRefPubMedGoogle Scholar

Copyright information

© Humana Press Inc. 2007

Authors and Affiliations

  • T. G. Devlin
    • 1
  • B. W. Baxter
    • 1
  • T. A. Feintuch
    • 1
  • N. A. Desbiens
    • 1
  1. 1.Division of Neurology, Department of MedicineUniversity of Tennessee College of Medicine-Chattanooga UnitChattanooga

Personalised recommendations