TY - JOUR
T1 - Endovascular therapy for ischemic stroke with perfusion-imaging selection
AU - Campbell, Bruce C.V.
AU - Mitchell, Peter J.
AU - Kleinig, Timothy J.
AU - Dewey, Helen M.
AU - Churilov, Leonid
AU - Yassi, Nawaf
AU - Yan, Bernard
AU - Dowling, Richard J.
AU - Parsons, Mark W.
AU - Oxley, Thomas J.
AU - Wu, Teddy Y.
AU - Brooks, Mark
AU - Simpson, Marion A.
AU - Miteff, Ferdinand
AU - Levi, Christopher R.
AU - Krause, Martin
AU - Harrington, Timothy J.
AU - Faulder, Kenneth C.
AU - Steinfort, Brendan S.
AU - Priglinger, Miriam
AU - Ang, Timothy
AU - Scroop, Rebecca
AU - Barber, P. Alan
AU - McGuinness, Ben
AU - Wijeratne, Tissa
AU - Phan, Thanh G.
AU - Chong, Winston
AU - Chandra, Ronil V.
AU - Bladin, Christopher F.
AU - Badve, Monica
AU - Rice, Henry
AU - De Villiers, Laetitia
AU - Ma, H.
AU - Desmond, P. M.
AU - Donnan, Geoffrey A.
AU - Davis, Stephen M.
PY - 2015/3/12
Y1 - 2015/3/12
N2 - Background: Trials of endovascular therapy for ischemic stroke have produced variable results. We conducted this study to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes. Methods: We randomly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (.8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days. Results: The trial was stopped early because of efficacy after 70 patients had undergone randomization (35 patients in each group). The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group (median, 100% vs. 37%; P<0.001). Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P = 0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P = 0.01). There were no significant differences in rates of death or symptomatic intracerebral hemorrhage. Conclusions: In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome. (Funded by the Australian National Health and Medical Research Council and others; EXTEND-IA ClinicalTrials.gov number, NCT01492725, and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965.)
AB - Background: Trials of endovascular therapy for ischemic stroke have produced variable results. We conducted this study to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes. Methods: We randomly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (.8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days. Results: The trial was stopped early because of efficacy after 70 patients had undergone randomization (35 patients in each group). The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group (median, 100% vs. 37%; P<0.001). Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P = 0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P = 0.01). There were no significant differences in rates of death or symptomatic intracerebral hemorrhage. Conclusions: In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome. (Funded by the Australian National Health and Medical Research Council and others; EXTEND-IA ClinicalTrials.gov number, NCT01492725, and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965.)
UR - http://www.scopus.com/inward/record.url?scp=84924663845&partnerID=8YFLogxK
U2 - 10.1056/NEJMoa1414792
DO - 10.1056/NEJMoa1414792
M3 - Article
C2 - 25671797
AN - SCOPUS:84924663845
SN - 0028-4793
VL - 372
SP - 1009
EP - 1018
JO - New England Journal of Medicine
JF - New England Journal of Medicine
IS - 11
ER -