Endovascular  Therapy  for  Ischemic  Stroke  with  Perfusion-­‐Imaging  Selec=on  RFS  Journal  Primer  

BOTTOM  LINE  •  Patients   with   proximal   anterior   cerebral   arterial   occlusion   and   salvageable   tissue   on   perfusion  

imaging   have   improved   outcomes   with   stent   retriever   intervention   (Solitaire   FR)   compared   to  alteplase  alone  

 MAJOR  POINTS    •  Percentage   of   ischemic   territory   reperfused   at   24   hours   was   signiAicantly   greater   in   the  

endovascular-­‐therapy  group  (median  100%)  than  in  the  alteplase-­‐only  group  (median  37%)  •  Endovascular  therapy,  initiated  at  a  median  of  210  minutes  after  the  onset  of  stroke,  increased  early  

neurologic   improvement   at   3   days   (80%  vs.   37%)   and   functional   outcome   at   90   days,  with  more  patients  achieving  functional  independence  (71%  vs.  40%)  

•  No  signiAicant  differences  in  rates  of  death  or  symptomatic  intracerebral  hemorrhage  

CRITICISM    •  Small  number  of  patients  •  Early  termination  of  the  trial  does  create  potential  for  overestimation  of  the  effect  size  •  Purely   volume-­‐based   criteria  do  not   account   for   the   location  of   the   core  which   is   also   relevant   to  

clinical  outcome  

Quick  Summary  

Multicenter Prospective Randomized Control Trial •  70  patients  (35  endovascular  therapy  and  35  alteplase  only)  at  10  centers  in  

Australia  and  New  Zealand  from  2012  to  2014,  terminated  early  due  to  efAicacy    

INCLUSION  CRITERIA  •  Patients  presenting  with  anterior  circulation  acute  ischemic  stroke  eligible  to  

receive  IV  alteplase  within  4.5  hours  of  stroke  onset  •  CT  perfusion  or  MR  perfusion:  Mismatch  ratio  of  greater  than  1.2,    absolute  

mismatch  volume  of  greater  than  10  ml,  and  ischemic  core  lesion  volume  of  less  than  70mL  

•  Endovascular  groin  puncture  within  6  hours  of  stroke  onset  •  Arterial  occlusion  of  the  ICA,  M1  or  M2  on  CTA/MRA  •  Functional  independence  prior  to  stroke  episode  (mRS<2)    EXCLUSION  CRITERIA  •  Rapidly  improving  symptoms  or  inability  to  access  cerebral  vasculature  at  the  

discretion  of  the  investigator  •  Standard  contraindications  to  endovascular  therapy  or  alteplase    

Study  design  

•  Trials  of  endovascular  therapy  for  ischemic  stroke  have  produced  variable  results  •  Can  recent  advancements  in  perfusion  imaging,  new  device  development,  and  earlier  

intervention  improve  outcomes?  

Purpose  

•  All  patients  received  alteplase  dose  of  0.9  mg/kg  as  standard  care  

•  CT  perfusion  imaging  using  fully  automated  software  to  determine  penumbra  and  core  (RAPID,  Stanford  University)  

•  Randomized  to  no  further  therapy  or  Solitaire  FR  retrievable  stent  (Covidien)  

•  Mean  time  from  symptom  onset  to  groin  puncture:  210  minutes  

•  Revascularization  graded  with  mTICI  score    

Interven7on  

Outcome    

•  Improved  median  perfusion  volume  at  24  hours  on  imaging  (100%  vs  37%)  

•  Increased  early  neurologic  improvement  deAined  as  >8  points  on  NIHSS  at  3  days  (80%  vs  37%)  

•  Improved  functional  independence  at  90  days  based  on  modiAied  Rankin  scale  (71%  vs  40%)  

•  Number  of  patient  needed  to  treat  endovascularly  to  achieve  an  additional  independence  outcome  as  compared  to  alteplase  alone:  3.2  

•  No  signiAicant  difference  in  symptomatic  intracerebral  hemorrhage,  parenchymal  hematoma,  or  mortality  

 

Credits  

SUMMARY  BY:    Zachary  Zhang,  M.D.,  PGY-­‐4  Department  of  Radiology  Rochester  Regional  Health  System    FULL  CITATION:  Campbell  BC,  Mitchell  PJ,  Kleinig  TJ,  et  al.  Endovascular  therapy  for  ischemic  stroke  with  perfusion-­‐imaging  selection.  N  Engl  J  Med.  2015;  372(11):1009-­‐1018.  

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