• Temple EM

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging

Background: Thrombectomy has currently been utilized as a management modality for patients who present with a stroke within 6 hours. However, little research has been done to assess the utility in patients who present within the 6-16 hour window, which can be a big deal clinically when patients wake up with new stroke symptoms and an unclear timeline for when the symptoms began.

The Study: This study was a multicenter-randomized open-label trial with blinded assessment of patients who presented with a proximal middle-cerebral-artery or internal-carotid artery occlusion within 6-16 hours from symptom onset. These strokes were confirmed on either CT perfusion or MRI diffusion and perfusion scans. The initial infarct size had to be less than 70 ml and the ratio of volume of ischemic tissue to infarct volume had to be 1.8 or more. These patients were randomly assigned to either receive endovascular thrombectomy with standard medical therapy or just standard medical therapy alone. The primary outcome was the patient’s modified Rankin scale at day 90 (assessment of functional ability).

Results: This study was stopped early as the results of this study were so profound. Endovascular therapy with standard medical therapy was associated with associated with improved functional outcomes (higher modified rankin scores). They also had a lower 90-day mortality rate (14% versus 26%) and no significant differences in the frequency of symptomatic intracranial hemorrhage or other serious adverse events.

The Takeaway: Consider thrombectomy for patients who present with a proximal middle-cerebral-artery or internal-carotid artery stroke with the onset of their symptoms within 6-16 hours. This treatment modality has been shown to have better functional outcomes and less mortality with no increased in serious adverse events.

http://www.nejm.org/doi/full/10.1056/NEJMoa1713973

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