title: Endovascular therapy for ischemic stroke with perfusion-imaging selection.
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 ClinicalTrials.gov number, NCT01492725, and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965.).
authors: The authors' affiliations are listed in the Appendix.
authors: Bruce C V
authors: BC
authors: Campbell
authors: Peter J
authors: PJ
authors: Mitchell
authors: Timothy J
authors: TJ
authors: Kleinig
authors: Helen M
authors: HM
authors: Dewey
authors: Leonid
authors: L
authors: Churilov
authors: Nawaf
authors: N
authors: Yassi
authors: Bernard
authors: B
authors: Yan
authors: Richard J
authors: RJ
authors: Dowling
authors: Mark W
authors: MW
authors: Parsons
authors: Thomas J
authors: TJ
authors: Oxley
authors: Teddy Y
authors: TY
authors: Wu
authors: Mark
authors: M
authors: Brooks
authors: Marion A
authors: MA
authors: Simpson
authors: Ferdinand
authors: F
authors: Miteff
authors: Christopher R
authors: CR
authors: Levi
authors: Martin
authors: M
authors: Krause
authors: Timothy J
authors: TJ
authors: Harrington
authors: Kenneth C
authors: KC
authors: Faulder
authors: Brendan S
authors: BS
authors: Steinfort
authors: Miriam
authors: M
authors: Priglinger
authors: Timothy
authors: T
authors: Ang
authors: Rebecca
authors: R
authors: Scroop
authors: P Alan
authors: PA
authors: Barber
authors: Ben
authors: B
authors: McGuinness
authors: Tissa
authors: T
authors: Wijeratne
authors: Thanh G
authors: TG
authors: Phan
authors: Winston
authors: W
authors: Chong
authors: Ronil V
authors: RV
authors: Chandra
authors: Christopher F
authors: CF
authors: Bladin
authors: Monica
authors: M
authors: Badve
authors: Henry
authors: H
authors: Rice
authors: Laetitia
authors: L
authors: de Villiers
authors: Henry
authors: H
authors: Ma
authors: Patricia M
authors: PM
authors: Desmond
authors: Geoffrey A
authors: GA
authors: Donnan
authors: Stephen M
authors: SM
authors: Davis
mesh_terms: D000368:Aged; D015901:Angiography, Digital Subtraction; D002545:Brain Ischemia / Q000175:diagnosis / Q000628:therapy; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging; D003131:Combined Modality Therapy; D057510:Endovascular Procedures; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging*; D055420:Perfusion Imaging; D015424:Reperfusion; D016037:Single-Blind Method; D015607:Stents; D020521:Stroke / Q000628:therapy*; D017131:Thrombectomy / Q000295:instrumentation; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014055:Tomography, Emission-Computed
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator