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Endovascular Therapy for Ischemic Stroke with Perfusion-‐Imaging Selec=on RFS Journal Primer
BOTTOM LINE • Patients with proximal anterior cerebral arterial occlusion and salvageable tissue on perfusion
imaging have improved outcomes with stent retriever intervention (Solitaire FR) compared to alteplase alone
MAJOR POINTS • Percentage of ischemic territory reperfused at 24 hours was signiAicantly greater in the
endovascular-‐therapy group (median 100%) than in the alteplase-‐only group (median 37%) • Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early
neurologic improvement at 3 days (80% vs. 37%) and functional outcome at 90 days, with more patients achieving functional independence (71% vs. 40%)
• No signiAicant differences in rates of death or symptomatic intracerebral hemorrhage
CRITICISM • Small number of patients • Early termination of the trial does create potential for overestimation of the effect size • Purely volume-‐based criteria do not account for the location of the core which is also relevant to
clinical outcome
Quick Summary
Multicenter Prospective Randomized Control Trial • 70 patients (35 endovascular therapy and 35 alteplase only) at 10 centers in
Australia and New Zealand from 2012 to 2014, terminated early due to efAicacy
INCLUSION CRITERIA • Patients presenting with anterior circulation acute ischemic stroke eligible to
receive IV alteplase within 4.5 hours of stroke onset • CT perfusion or MR perfusion: Mismatch ratio of greater than 1.2, absolute
mismatch volume of greater than 10 ml, and ischemic core lesion volume of less than 70mL
• Endovascular groin puncture within 6 hours of stroke onset • Arterial occlusion of the ICA, M1 or M2 on CTA/MRA • Functional independence prior to stroke episode (mRS<2) EXCLUSION CRITERIA • Rapidly improving symptoms or inability to access cerebral vasculature at the
discretion of the investigator • Standard contraindications to endovascular therapy or alteplase
Study design
• Trials of endovascular therapy for ischemic stroke have produced variable results • Can recent advancements in perfusion imaging, new device development, and earlier
intervention improve outcomes?
Purpose
• All patients received alteplase dose of 0.9 mg/kg as standard care
• CT perfusion imaging using fully automated software to determine penumbra and core (RAPID, Stanford University)
• Randomized to no further therapy or Solitaire FR retrievable stent (Covidien)
• Mean time from symptom onset to groin puncture: 210 minutes
• Revascularization graded with mTICI score
Interven7on
Outcome
• Improved median perfusion volume at 24 hours on imaging (100% vs 37%)
• Increased early neurologic improvement deAined as >8 points on NIHSS at 3 days (80% vs 37%)
• Improved functional independence at 90 days based on modiAied Rankin scale (71% vs 40%)
• Number of patient needed to treat endovascularly to achieve an additional independence outcome as compared to alteplase alone: 3.2
• No signiAicant difference in symptomatic intracerebral hemorrhage, parenchymal hematoma, or mortality
Credits
SUMMARY BY: Zachary Zhang, M.D., PGY-‐4 Department of Radiology Rochester Regional Health System FULL CITATION: Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-‐imaging selection. N Engl J Med. 2015; 372(11):1009-‐1018.
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