Background
Whether brain imaging can identify patients who are most likely to benefit from
therapies for acute ischemic stroke and whether endovascular thrombectomy improves
clinical outcomes in such patients remains unclear.
Methods
In this study, we randomly assigned patients within 8 hours after the onset of largevessel,
anterior-circulation strokes to undergo mechanical embolectomy (Merci
Retriever or Penumbra System) or receive standard care. All patients underwent
pretreatment computed tomography or magnetic resonance imaging of the brain.
Randomization was stratified according to whether the patient had a favorable
penumbral pattern (substantial salvageable tissue and small infarct core) or a nonpenumbral
pattern (large core or small or absent penumbra). We assessed outcomes
using the 90-day modified Rankin scale, ranging from 0 (no symptoms) to 6 (dead).
Results
Among 118 eligible patients, the mean age was 65.5 years, the mean time to enrollment
was 5.5 hours, and 58% had a favorable penumbral pattern. Revascularization
in the embolectomy group was achieved in 67% of the patients. Ninety-day mortality
was 21%, and the rate of symptomatic intracranial hemorrhage was 4%; neither rate
differed across groups. Among all patients, mean scores on the modified Rankin
scale did not differ between embolectomy and standard care (3.9 vs. 3.9, P = 0.99).
Embolectomy was not superior to standard care in patients with either a favorable
penumbral pattern (mean score, 3.9 vs. 3.4; P = 0.23) or a nonpenumbral pattern
(mean score, 4.0 vs. 4.4; P = 0.32). In the primary analysis of scores on the 90-day
modified Rankin scale, there was no interaction between the pretreatment imaging
pattern and treatment assignment (P = 0.14).
Conclusions
A favorable penumbral pattern on neuroimaging did not identify patients who would
differentially benefit from endovascular therapy for acute ischemic stroke, nor was
embolectomy shown to be superior to standard care. (Funded by the National Institute
of Neurological Disorders
Whether brain imaging can identify patients who are most likely to benefit from
therapies for acute ischemic stroke and whether endovascular thrombectomy improves
clinical outcomes in such patients remains unclear.
Methods
In this study, we randomly assigned patients within 8 hours after the onset of largevessel,
anterior-circulation strokes to undergo mechanical embolectomy (Merci
Retriever or Penumbra System) or receive standard care. All patients underwent
pretreatment computed tomography or magnetic resonance imaging of the brain.
Randomization was stratified according to whether the patient had a favorable
penumbral pattern (substantial salvageable tissue and small infarct core) or a nonpenumbral
pattern (large core or small or absent penumbra). We assessed outcomes
using the 90-day modified Rankin scale, ranging from 0 (no symptoms) to 6 (dead).
Results
Among 118 eligible patients, the mean age was 65.5 years, the mean time to enrollment
was 5.5 hours, and 58% had a favorable penumbral pattern. Revascularization
in the embolectomy group was achieved in 67% of the patients. Ninety-day mortality
was 21%, and the rate of symptomatic intracranial hemorrhage was 4%; neither rate
differed across groups. Among all patients, mean scores on the modified Rankin
scale did not differ between embolectomy and standard care (3.9 vs. 3.9, P = 0.99).
Embolectomy was not superior to standard care in patients with either a favorable
penumbral pattern (mean score, 3.9 vs. 3.4; P = 0.23) or a nonpenumbral pattern
(mean score, 4.0 vs. 4.4; P = 0.32). In the primary analysis of scores on the 90-day
modified Rankin scale, there was no interaction between the pretreatment imaging
pattern and treatment assignment (P = 0.14).
Conclusions
A favorable penumbral pattern on neuroimaging did not identify patients who would
differentially benefit from endovascular therapy for acute ischemic stroke, nor was
embolectomy shown to be superior to standard care. (Funded by the National Institute
of Neurological Disorders
Blogger comment: key point here is mean time to vascularization has to be less than 8 hours. MR rescue should be done within six or preferably four hours.
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