Search

BACKGROUND The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy. METHODS We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (= 80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days. RESULTS A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference [Bayesian analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P = 0.50), nor did 90-day mortality (19% and 18%, respectively; P = 1.00). CONCLUSIONS Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. (Funded by Stryker Neurovascular; DAWN ClinicalTrials.gov number, NCT02142283.)

Although many stroke centers worldwide have performed endovascular stroke therapy since the results of the Prolyse in Acute Cerebral Thromboembolism (PROACT) II trial were published in 1999,1 lingering uncertainties about efficacy and the selection of patients created an uneasy equipoise. Especially nettlesome was the uncertain benefit of endovascular therapy as compared with intravenous tissue plasminogen activator (t-PA). The controversy over endovascular therapy was heightened in 2013 when the results of the Interventional Management of Stroke (IMS) III,2 Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE),3 and Local versus Systemic Thrombolysis for Acute Ischemic Stroke (SYNTHESIS Expansion)4 clinical . . .

As compared with carotid endarterectomy, carotid-artery stenting has uncertain efficacy and safety in patients at risk for stroke from atherosclerotic stenosis of the internal carotid artery. The benefits of carotid endarterectomy for both symptomatic and asymptomatic patients have been established in several randomized trials comparing surgery with medical therapy. The benefits of surgery in reducing the long-term risk of stroke need to be weighed against the immediate risk of death or stroke as a complication of the surgery. For symptomatic patients with stenosis of the internal carotid artery of 70% or more, carotid endarterectomy is superior to medical therapy alone, . . .