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Type: Journal article
Title: Endovascular therapy for ischemic stroke with perfusion-imaging selection
Author: Campbell, B.
Mitchell, P.
Kleinig, T.
Dewey, H.
Churilov, L.
Yassi, N.
Yan, B.
Dowling, R.
Parsons, M.
Oxley, T.
Wu, T.
Brooks, M.
Simpson, M.
Miteff, F.
Levi, C.
Krause, M.
Harrington, T.
Faulder, K.
Steinfort, B.
Priglinger, M.
et al.
Citation: New England Journal of Medicine, 2015; 372(11):1009-1018
Publisher: Massachussetts Medical Society
Issue Date: 2015
ISSN: 0028-4793
Statement of
Bruce C.V. Campbell ... Timothy J. Kleinig ... et al. for the EXTEND-IA Investigator
Abstract: BACKGROUND: Trials of endovascular therapy for ischemic stroke have produced variable results. We conducted this study to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes. METHODS: We randomly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (≥8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days. RESULTS: The trial was stopped early because of efficacy after 70 patients had undergone randomization (35 patients in each group). The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group (median, 100% vs. 37%; P<0.001). Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P=0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P=0.01). There were no significant differences in rates of death or symptomatic intracerebral hemorrhage. CONCLUSIONS: In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome. (Funded by the Australian National Health and Medical Research Council and others; EXTEND-IA number, NCT01492725, and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965.).
Keywords: Humans
Carotid Artery, Internal
Middle Cerebral Artery
Brain Ischemia
Tissue Plasminogen Activator
Angiography, Digital Subtraction
Fibrinolytic Agents
Tomography, Emission-Computed
Combined Modality Therapy
Single-Blind Method
Middle Aged
Perfusion Imaging
Rights: © 2015 Massachusetts Medical Society. All rights reserved.
DOI: 10.1056/NEJMoa1414792
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