J W Evans1, B R Graham1, P Pordeli2, F S Al-Ajlan1, R Willinsky3, W J Montanera3, J L Rempel4, A Shuaib5, P Brennan6, D Williams7, D Roy8, A Y Poppe9, T G Jovin10, T Devlin11, B W Baxter12, T Krings13, F L Silver14, D F Frei15, C Fanale14, D Tampieri15, J Teitelbaum16, D Iancu17, J Shankar18, P A Barber1,19, A M Demchuk1,19, M Goyal1,19, M D Hill1,2,19, B K Menon20,2,19,21. 1. From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.). 2. Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. 3. Department of Medical Imaging (R.W., W.J.M.). 4. Departments of Radiology (J.L.R.). 5. Medicine (Neurology) (A.S.), University of Alberta, Edmonton, Alberta, Canada. 6. Departments of Neuroradiology (P.B.). 7. Geriatric and Stroke Medicine (D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland. 8. Departments of Radiology (D.R.). 9. Neurosciences (A.Y.P.), Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada. 10. Department of Neurology (T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. 11. Erlanger Medical Centre (T.D.). 12. Department of Radiology (B.W.B), Erlanger Hospital, University of Tennessee, Chattanooga, Tennessee. 13. Division of Radiology (T.K.). 14. Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada. 15. Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado. 16. Montreal Neurological Institute (J.T.), McGill University, Montreal, Quebec, Canada. 17. Department of Radiology (D.I.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada. 18. Department of Neuroradiology (J.S.), Dalhousie University, Halifax, Nova Scotia, Canada. 19. Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada. 20. From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.) docbijoymenon@gmail.com. 21. Foothills Medical Centre (B.K.M.), Calgary, Alberta, Canada.
Abstract
BACKGROUND AND PURPOSE: The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS:Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS: There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS: Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.
RCT Entities:
BACKGROUND AND PURPOSE: The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS: Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS: There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS:Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.
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