Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging

G. W. Albers*, M. P. Marks, S. Kemp, S. Christensen, J. P. Tsai, S. Ortega-Gutierrez, R. A. McTaggart, M. T. Torbey, M. Kim-Tenser, T. Leslie-Mazwi, A. Sarraj, S. E. Kasner, S. A. Ansari, S. D. Yeatts, S. Hamilton, M. Mlynash, J. J. Heit, G. Zaharchuk, S. Kim, J. CarrozzellaY. Y. Palesch, A. M. Demchuk, R. Bammer, P. W. Lavori, J. P. Broderick, M. G. Lansberg

*Corresponding author for this work

Research output: Contribution to journalArticle

1172 Scopus citations

Abstract

BACKGROUND: Thrombectomy is currently recommended for eligible patients with stroke who are treated within 6 hours after the onset of symptoms. METHODS: We conducted a multicenter, randomized, open-label trial, with blinded outcome assessment, of thrombectomy in patients 6 to 16 hours after they were last known to be well and who had remaining ischemic brain tissue that was not yet infarcted. Patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion, an initial infarct size of less than 70 ml, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct volume of 1.8 or more were randomly assigned to endovascular therapy (thrombectomy) plus standard medical therapy (endovascular-therapy group) or standard medical therapy alone (medical-therapy group). The primary outcome was the ordinal score on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at day 90. RESULTS: The trial was conducted at 38 U.S. centers and terminated early for efficacy after 182 patients had undergone randomization (92 to the endovascular-therapy group and 90 to the medical-therapy group). Endovascular therapy plus medical therapy, as compared with medical therapy alone, was associated with a favorable shift in the distribution of functional outcomes on the modified Rankin scale at 90 days (odds ratio, 2.77; P<0.001) and a higher percentage of patients who were functionally independent, defined as a score on the modified Rankin scale of 0 to 2 (45% vs. 17%, P<0.001). The 90-day mortality rate was 14% in the endovascular-therapy group and 26% in the medical-therapy group (P = 0.05), and there was no significant between-group difference in the frequency of symptomatic intracranial hemorrhage (7% and 4%, respectively; P = 0.75) or of serious adverse events (43% and 53%, respectively; P = 0.18). CONCLUSIONS: Endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well plus standard medical therapy resulted in better functional outcomes than standard medical therapy alone among patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion and a region of tissue that was ischemic but not yet infarcted.

Original languageEnglish (US)
Pages (from-to)708-718
Number of pages11
JournalNew England Journal of Medicine
Volume378
Issue number8
DOIs
StatePublished - Feb 22 2018

ASJC Scopus subject areas

  • Medicine(all)

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