Endovascular Thrombectomy Plus Medical Therapy Improves Outcomes in Patients With Acute Ischaemic Stroke: Presented at ESC

By Chris Berrie

ATHENS, Greece -- April 16, 2018 -- Endovascular thrombectomy plus medical therapy provides significantly improved clinical and functional outcomes at 90 days over medical therapy alone for patients with acute ischaemic stroke, according to a study presented here at the 27th European Stroke Conference (ESC).

Over the past few years, endovascular therapy has been shown to be a viable option for stroke treatment, with 5 trials showing the unequivocal value of mechanical thrombectomy.

“Of note, 2 trials, EXTEND-1A and SWIFT PRIME, used perfusion imaging as patient selection criteria,” indicated Randolph S. Marshall, MD, MS, Columbia University Medical Center, New York, New York, on April 12.

In this study (NCT02586415), this information was applied by researchers to define their population of patients with acute ischaemic anterior circulation strokes caused by large artery occlusion who had treatment started 6 to 16 hours from stroke onset.

The procedure included femoral puncture within 90 minutes of randomisation, with angioplasty/stenting allowed, general anaesthetic discouraged, and arterial tissue plasminogen activator not allowed. All patients underwent magnetic resonance or computed tomography core and prenumbra imaging at baseline and 24 hours, with angiography for occlusion at baseline and postprocedural recanalisation.

After stratification according to ischaemic core lesion volume, National Institutes of Health Stroke Scale (NIHSS) score, age, and time from symptom onset, patients were randomised to medical therapy without (control) and with endovascular thrombectomy. The planned sample size of 476 patients was not reached because the study was stopped early following the positive results of the DAWN trial.

The final efficacy assessments included 90 control patients (median age, 71 years; 51% female) and 92 patients who underwent endovascular thrombectomy (median age, 70 years; 50% female). Baseline clinical characteristics were similar in the groups, with median NIHSS scores of 16 and 16, median core volumes of 10.1 and 9.4 mL, median lesion volumes of 116.1 and 114.7 mL, and mainly occlusion of the middle cerebral artery (60%/ 65%), respectively.

The coprimary efficacy outcomes were modified Rankin scale (mRS) and functional independence (mRS 0-2) at 90 days. Compared with the control group, the endovascular thrombectomy group showed significant improvement in mRS score (adjusted odds ratio [OR], 3.4; P = .0004), with the definition of the number needed to treat of 2. Functional independence was also significantly improved (17% vs 45%; P< .0001).

The patient benefits from endovascular thrombectomy were accompanied by significantly improved reperfusion (18% vs 79%; P< .0001) and recanalisation (18% vs 78%; P< .0001).

Death at 90 days was reduced with endovascular thrombectomy (26% vs 14%; P = .05), whereas symptomatic intracerebral haemorrhage within 36 hours was similar in the groups (4.4% vs 6.5%).

A series of subgroup analyses indicated that the benefits of endovascular thrombectomy were consistent across the subgroups analysed, particularly in terms of baseline NIHSS score, wake-up versus witnessed onset stroke, and infarct core growth.

“Overall, these are very positive results,” concluded Dr. Marshall after comparisons with data obtained recently in the DAWN trial.

[Presentation title: The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke (DEFUSE-3)… and Beyond]

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