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Question clinique
Does the use of endovascular therapy improve functional outcomes for patients with acute stroke with large ischemic regions?
L’Essentiel
For large ischemic strokes, adding endovascular therapy results in better functional outcomes at 90 days than using medical therapy alone (number needed to treat [NNT] = 6), but also leads to more intracranial bleeds (NNT = 4). 1b
Référence
Plan de l'etude: Randomized controlled trial (nonblinded)
Financement: Government
Cadre: Inpatient (any location) with outpatient follow-up
Sommaire
In this multicenter trial in Japan, investigators enrolled patients who presented to the hospital with an acute ischemic stroke caused by a large vessel occlusion leading to a large area of infarct. Patients were randomized, using concealed allocation, to receive either endovascular therapy (eg, angioplasty, intracranial stenting, and so forth) plus medical care (n = 101) or medical care alone (n = 102). Those patients with a clinically significant cerebral mass effect, intracranial bleed, or at high risk for such a bleed were excluded. Both groups received alteplase, if indicated, at the discretion of the treating physician. Baseline characteristics were similar in the 2 groups. The primary outcome was improved functional status at 90 days after stroke, defined as a score of 0 to 3 on the modified Rankin scale (mRS; from 0 - 6, with 0 indicating no disability). Overall, 27% of patients in each group received alteplase. The endovascular therapy group fared better, with a higher percentage of patients with an mRS score of 0 to 3 at 90 days (31% vs 13%; P = .002). Although patients in the endovascular therapy group were more likely to have an intracranial bleed within 48 hours (58% vs 32%; P < .001), there were no significant differences in symptomatic intracranial bleeds within 48 hours or recurrence of ischemic stroke or death within 90 days. Of note, the dose of alteplase used in Japan is lower than in other countries and may have affected both efficacy and safety outcomes in the 2 groups.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Commentaires
Endovascular therapy over medical management in CVA
No appreciable difference in management in both lines .. medical management avoids risk of bleed within 48hours in large ischemic stroke patients
alteplase for large ischemia cva's
better results at 90 days, than no rx