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Endovascular Treatment of Stroke | Journal Scan
Study Questions:
What is the utility of rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation?
Methods:
The ESCAPE trial investigators randomized patients with stroke associated with a proximal intracranial occlusion in the anterior circulation up to 12 hours after symptom onset to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days.
Results:
The trial was prematurely terminated due to efficacy after 316 participants had been enrolled. Alteplase was administered to 238 of the 316 patients (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. Intervention was associated with an improved rate of functional independence (90-day modified Rankin score of 0-2, 53.0%, vs. 29.3% in the control group; p < 0.001). Intervention was associated with an improved primary outcome (common odds ratio, 2.6; 95% confidence interval, 1.7-3.8; p < 0.001), and reduced mortality (10.4%, vs. 19.0% in the control group; p = 0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in the intervention group and 2.7% of participants in the control group (p = 0.75).
Conclusions:
Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality.
Perspective:
Among patients with a proximal vessel occlusion in the anterior circulation, the majority of patients die within 90 days after stroke onset, or do not regain functional independence despite alteplase treatment. This study demonstrates that contemporary endovascular therapy of large stroke is associated with dramatic clinical benefit both in terms of morbidity and mortality. The study mandated and achieved rapid endovascular therapy, and it is likely that this speedy reperfusion was the key to the improved outcomes seen with this approach. Widespread clinical application of this approach requires creation of rapid care systems that can provide efficient and timely endovascular reperfusion for stroke.
Keywords: Stroke, Endovascular Procedures, Thrombectomy, Tissue Plasminogen Activator, Collateral Circulation, Intracranial Hemorrhages, Cerebral Hemorrhage, Tomography, Angiography, Control Groups
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