Endovascular therapy for ischemic stroke with perfusion-imaging selection.
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Campbell Bruce C V, Mitchell Peter J, Kleinig Timothy J, Dewey Helen M, Churilov Leonid, Yassi Nawaf, Yan Bernard, Dowling Richard J, Parsons Mark W, Oxley Thomas J, Wu Teddy Y, Brooks Mark, Simpson Marion A, Miteff Ferdinand, Levi Christopher R, Krause Martin, Harrington Timothy J, Faulder Kenneth C, Steinfort Brendan S, Priglinger Miriam, Ang Timothy, Scroop Rebecca, Barber P Alan, McGuinness Ben, Wijeratne Tissa, Phan Thanh G, Chong Winston, Chandra Ronil V, Bladin Christopher F, Badve Monica, Rice Henry, de Villiers Laetitia, Ma Henry, Desmond Patricia M, Donnan Geoffrey A, Davis Stephen M, EXTEND-IA Investigators
Аннотация
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.).