Endovascular

Therapy for Ischemic Stroke with

Perfusion-Imaging Selec=on
RFS Journal Primer

Quick Summary
BOTTOM LINE

Patients with proximal anterior cerebral arterial occlusion and salvageable tissue on perfusion
imaging have improved outcomes with stent retriever intervention (Solitaire FR) compared to
alteplase alone

MAJOR POINTS

Percentage of ischemic territory reperfused at 24 hours was signiAicantly greater in the

endovascular-therapy group (median 100%) than in the alteplase-only group (median 37%)

Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early
neurologic improvement at 3 days (80% vs. 37%) and functional outcome at 90 days, with more
patients achieving functional independence (71% vs. 40%)

No signiAicant differences in rates of death or symptomatic intracerebral hemorrhage

CRITICISM

Small number of patients

Early termination of the trial does create potential for overestimation of the effect size

Purely volume-based criteria do not account for the location of the core which is also relevant to
clinical outcome

Study design
Multicenter Prospective Randomized Control Trial

70 patients (35 endovascular therapy and 35 alteplase only) at 10 centers in

Australia and New Zealand from 2012 to 2014, terminated early due to efAicacy

INCLUSION CRITERIA

Patients presenting with anterior circulation acute ischemic stroke eligible to

receive IV alteplase within 4.5 hours of stroke onset

CT perfusion or MR perfusion: Mismatch ratio of greater than 1.2, absolute

mismatch volume of greater than 10 ml, and ischemic core lesion volume of less
than 70mL

Endovascular groin puncture within 6 hours of stroke onset

Arterial occlusion of the ICA, M1 or M2 on CTA/MRA

Functional independence prior to stroke episode (mRS<2)

EXCLUSION CRITERIA

Rapidly improving symptoms or inability to access cerebral vasculature at the

discretion of the investigator

Standard contraindications to endovascular therapy or alteplase

Purpose

Trials of endovascular therapy for ischemic stroke have produced variable results

Can recent advancements in perfusion imaging, new device development, and earlier
intervention improve outcomes?

Interven7on

All patients received alteplase dose of 0.9

mg/kg as standard care

CT perfusion imaging using fully automated

software to determine penumbra and core
(RAPID, Stanford University)

Randomized to no further therapy or

Solitaire FR retrievable stent (Covidien)

Mean time from symptom onset to groin

puncture: 210 minutes

Revascularization graded with mTICI score

Outcome

Improved median perfusion volume at 24 hours

on imaging (100% vs 37%)

Increased early neurologic improvement deAined

as >8 points on NIHSS at 3 days (80% vs 37%)

Improved functional independence at 90 days

based on modiAied Rankin scale (71% vs 40%)

Number of patient needed to treat endovascularly

to achieve an additional independence outcome as
compared to alteplase alone: 3.2

No signiAicant difference in symptomatic

intracerebral hemorrhage, parenchymal
hematoma, or mortality

Credits

SUMMARY BY:

Zachary Zhang, M.D., PGY-4
Department of Radiology
Rochester Regional Health System

FULL CITATION:
Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med.
2015; 372(11):1009-1018.

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