Better functional outcomes, but more bleeds with endovascular therapy for large ischemic strokes

Reference

Yoshimura S, Sakai N, Yamagami H, et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med 2022;386(14):1303-1313.

Synopsis

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.