Does endovascular thrombectomy improve outcomes in patients with acute large ischemic strokes?
In patients with large acute ischemic strokes, thrombectomy plus standard medical care, as compared with standard medical care alone, leads to better functional outcomes, but is associated with procedural complications.
Plan de l'etude:
Randomized controlled trial (nonblinded)
Inpatient (any location) with outpatient follow-up
The benefit of thrombectomy for patients with acute ischemic strokes with large areas of infarction has not been well established. In this international multicenter study, investigators recruited adults 18 to 85 years old who presented with an acute ischemic stroke due to occlusion of the internal carotid artery and/or the middle cerebral artery. Those with a large area of infarction based on specific imaging criteria and who had a baseline modified Rankin scale score (mRS) of 0 or 1 (range 0 - 6; higher scores indicate greater disability) were eligible for the trial. Using concealed allocation, patients were randomized to receive endovascular thrombectomy within 24 hours of stroke onset plus standard medical care (n = 178), or standard medical care alone (n = 174). Trial enrollment was stopped early because of efficacy. Baseline characteristics were similar in the 2 groups, with a median age of 66.5 years and a median National Institutes of Health Stroke Scale of 19 (range 0 - 42; higher scores indicate greater neurologic deficits). Approximately 20% of patients in each group received intravenous thrombolysis. For the primary outcome of mRS score at 90 days, the thrombectomy group fared better (mRS score = 4) than the standard care group (mRS score = 5; odds ratio 1.51; 95% CI 1.20 - 1.89; P <.001). Additionally, at 90 days, patients in the thrombectomy group were more likely to be functionally independent (20.3% vs 7.0%) and to be able to ambulate independently (37.9% vs 18.7%). Overall, there were very few symptomatic intracranial bleeds in the 2 groups (1 in thrombectomy group vs 2 in standard care group). The thrombectomy group had a higher percentage of early neurologic worsening (24.7% vs 15.5%), which the authors postulated might have been due to brain edema from reperfusion. Finally, 18.5% of patients in the thrombectomy group experienced procedural complications ranging from access site occlusion to vascular dissection. A trial conducted in China of endovascular therapy for large strokes showed similar results.
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine