Clinical question: Does endovascular treatment improve outcomes for patients with acute ischemic stroke?
Bottom line: For patients with acute ischemic stroke and imaging that suggests a proximal artery occlusion with evidence of good collateral circulation, the use of rapid endovascular treatment improves functional outcomes and reduces mortality. (LOE = 1b)
Reference: Goyal M, Demchuk AM, Menon BK, et al, for the ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372(11):1019-1030.
Study design: Randomized controlled trial (nonblinded)
Funding source: Industry
Setting: Inpatient (any location) with outpatient follow-up
The recent MR CLEAN study showed improved functional outcomes with the use of endovascular therapy for the treatment of acute ischemic stroke (N Engl J Med 2015;372:11-20).
In this study, investigators enrolled patients with acute disabling ischemic strokes and computed tomographic evidence of a small infarct core, an occluded proximal artery in the anterior circulation, and moderate-to-good collateral circulation. Patients were randomized, using concealed allocation, to receive either usual care or usual care plus rapid endovascular treatment with the use of mechanical thrombectomy and retrievable stents.
The 2 groups had similar baseline characteristics with a mean age of 70 years and a median National Institutes of Health Stroke Scale score of 16 to 17. The median time from stroke onset to reperfusion was 4 hours in the intervention group. The trial was stopped early because of the efficacy of the endovascular therapy. The primary outcome was a common odds ratio, indicating the odds of improvement by 1 point on the modified Rankin scale of 0 to 6 (0 = no symptoms, 1–2 = slight disability, 6 = death). This ratio favored the intervention (common odds ratio 2.6, 95% CI 1.7-3.8; P < .001).
Overall, at 90-day follow-up, the intervention group had a greater proportion of patients with a modified Rankin score of 0–2 (53% vs. 29%; P < .001), as well as decreased mortality (10% vs 19% in control group, P = .04). There was no difference between the 2 groups in the rate of symptomatic intracerebral bleeds.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.