title: A trial of imaging selection and endovascular treatment for ischemic stroke.
abstract: BACKGROUND
  Whether brain imaging can identify patients who are most likely to benefit from therapies for acute ischemic stroke and whether endovascular thrombectomy improves clinical outcomes in such patients remains unclear.
  
  
  METHODS
  In this study, we randomly assigned patients within 8 hours after the onset of large-vessel, anterior-circulation strokes to undergo mechanical embolectomy (Merci Retriever or Penumbra System) or receive standard care. All patients underwent pretreatment computed tomography or magnetic resonance imaging of the brain. Randomization was stratified according to whether the patient had a favorable penumbral pattern (substantial salvageable tissue and small infarct core) or a nonpenumbral pattern (large core or small or absent penumbra). We assessed outcomes using the 90-day modified Rankin scale, ranging from 0 (no symptoms) to 6 (dead).
  
  
  RESULTS
  Among 118 eligible patients, the mean age was 65.5 years, the mean time to enrollment was 5.5 hours, and 58% had a favorable penumbral pattern. Revascularization in the embolectomy group was achieved in 67% of the patients. Ninety-day mortality was 21%, and the rate of symptomatic intracranial hemorrhage was 4%; neither rate differed across groups. Among all patients, mean scores on the modified Rankin scale did not differ between embolectomy and standard care (3.9 vs. 3.9, P=0.99). Embolectomy was not superior to standard care in patients with either a favorable penumbral pattern (mean score, 3.9 vs. 3.4; P=0.23) or a nonpenumbral pattern (mean score, 4.0 vs. 4.4; P=0.32). In the primary analysis of scores on the 90-day modified Rankin scale, there was no interaction between the pretreatment imaging pattern and treatment assignment (P=0.14).
  
  
  CONCLUSIONS
  A favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular therapy for acute ischemic stroke, nor was embolectomy shown to be superior to standard care. (Funded by the National Institute of Neurological Disorders and Stroke; MR RESCUE ClinicalTrials.gov number, NCT00389467.).
authors: Department of Neurology and the Stroke Center, Georgetown University, Washington, DC 20007, USA. ck256@georgetown.edu
authors: Chelsea S
authors: CS
authors: Kidwell
authors: Reza
authors: R
authors: Jahan
authors: Jeffrey
authors: J
authors: Gornbein
authors: Jeffry R
authors: JR
authors: Alger
authors: Val
authors: V
authors: Nenov
authors: Zahra
authors: Z
authors: Ajani
authors: Lei
authors: L
authors: Feng
authors: Brett C
authors: BC
authors: Meyer
authors: Scott
authors: S
authors: Olson
authors: Lee H
authors: LH
authors: Schwamm
authors: Albert J
authors: AJ
authors: Yoo
authors: Randolph S
authors: RS
authors: Marshall
authors: Philip M
authors: PM
authors: Meyers
authors: Dileep R
authors: DR
authors: Yavagal
authors: Max
authors: M
authors: Wintermark
authors: Judy
authors: J
authors: Guzy
authors: Sidney
authors: S
authors: Starkman
authors: Jeffrey L
authors: JL
authors: Saver
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D001921:Brain / Q000000981:diagnostic imaging / Q000473:pathology; D002533:Cerebral Angiography; D004185:Disability Evaluation; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D059906:Neuroimaging; D016037:Single-Blind Method; D020521:Stroke / Q000175:diagnosis* / Q000188:drug therapy / Q000601:surgery*; D017131:Thrombectomy / Q000295:instrumentation; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
references: Neurology. 1998 Aug;51(2):418-26
references: 9710013
references: Stroke. 2011 Jul;42(7):1929-35
references: 21597019
references: Stroke. 2008 Apr;39(4):1205-12
references: 18309168
references: Lancet. 2012 Oct 6;380(9849):1231-40
references: 22932714
references: Int J Stroke. 2014 Jan;9(1):110-6
references: 22974139
references: Stroke. 2013 Feb;44(2):570-8
references: 23132783
references: Stroke. 2005 Jul;36(7):1432-8
references: 15961709
references: Stroke. 2013 Jan;44(1):73-9
references: 23233383
references: Lancet Neurol. 2012 Oct;11(10):860-7
references: 22954705
references: Stroke. 2009 Aug;40(8):2761-8
references: 19590057
references: AJNR Am J Neuroradiol. 2008 Mar;29(3):582-7
references: 18337393
references: N Engl J Med. 2008 Sep 25;359(13):1317-29
references: 18815396
references: Ann Neurol. 2006 Nov;60(5):508-17
references: 17066483
references: Lancet. 2012 Oct 6;380(9849):1241-9
references: 22932715
references: Lancet Neurol. 2011 Oct;10(10):909-21
references: 21939900
references: JAMA. 1999 Dec 1;282(21):2003-11
references: 10591382
references: N Engl J Med. 2012 Mar 22;366(12):1099-107
references: 22435369
references: Lancet Neurol. 2008 Apr;7(4):299-309
references: 18296121
references: N Engl J Med. 1995 Dec 14;333(24):1581-7
references: 7477192
references: Stroke. 1997 Apr;28(4):866-72
references: 9099209
references: Stroke. 2003 May;34(5):1317-23
references: 12663878