Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke

被引：4923

作者：

Goyal, M. ^{[1
,2
,4
]}

Demchuk, A. M. ^{[2
,4
]}

Menon, B. K. ^{[1
,2
,4
]}

Eesa, M. ^{[1
]}

Rempel, J. L. ^{[6
]}

Thornton, J. ^{[19
]}

Roy, D. ^{[8
]}

Jovin, T. G. ^{[22
]}

Willinsky, R. A. ^{[11
]}

Sapkota, B. L. ^{[28
]}

Dowlatshahi, D. ^{[15
]}

Frei, D. F. ^{[30
]}

Kamal, N. R. ^{[2
,4
]}

Montanera, W. J. ^{[13
]}

Poppe, A. Y. ^{[9
]}

Ryckborst, K. J. ^{[2
]}

Silver, F. L. ^{[12
]}

Shuaib, A. ^{[7
]}

Tampieri, D. ^{[10
]}

Williams, D. ^{[20
,21
]}

Bang, O. Y. ^{[31
]}

Baxter, B. W. ^{[29
]}

Burns, P. A. ^{[34
]}

Choe, H. ^{[24
]}

Heo, J. -H. ^{[32
]}

Holmstedt, C. A. ^{[35
]}

Jankowitz, B. ^{[23
]}

Kelly, M. ^{[16
]}

Linares, G. ^{[25
,26
,27
]}

Mandzia, J. L. ^{[17
]}

Shankar, J. ^{[18
]}

Sohn, S. -I. ^{[33
]}

Swartz, R. H. ^{[14
]}

Barber, P. A. ^{[1
,2
,4
]}

Coutts, S. B. ^{[2
,4
]}

Smith, E. E. ^{[2
,3
,4
]}

Morrish, W. F. ^{[1
]}

Weill, A. ^{[8
]}

Subramaniam, S. ^{[2
]}

Mitha, A. P. ^{[2
,4
]}

Wong, J. H. ^{[2
,4
]}

Lowerison, M. W. ^{[5
]}

Sajobi, T. T. ^{[3
]}

Hill, M. D. ^{[1
,2
,3
,4
]}

机构：

[1] Univ Calgary, Dept Radiol, Calgary, AB T2N 2T9, Canada

[2] Univ Calgary, Dept Clin Neurosci, Calgary, AB T2N 2T9, Canada

[3] Univ Calgary, Dept Community Hlth Sci, Calgary, AB T2N 2T9, Canada

[4] Univ Calgary, Hotchkiss Brain Inst, Calgary, AB T2N 2T9, Canada

[5] Univ Calgary, Clin Res Unit, Calgary, AB T2N 2T9, Canada

[6] Univ Alberta, Dept Neurosurg, Edmonton, AB, Canada

[7] Univ Alberta, Dept Med Neurol, Edmonton, AB, Canada

[8] Univ Montreal, Dept Radiol, Montreal, PQ, Canada

[9] Univ Montreal, Dept Neurosci, Montreal, PQ, Canada

[10] McGill Univ, Montreal Neurol Inst, Montreal, PQ, Canada

[11] Univ Toronto, Dept Med Imaging, Toronto, ON, Canada

[12] Univ Toronto, Toronto Gen Hosp, Div Neurol, Dept Med, Toronto, ON M5G 1L7, Canada

[13] Univ Toronto, St Michaels Hosp, Dept Med Imaging, Toronto, ON, Canada

[14] Univ Toronto, Dept Med, Sunnybrook Hlth Sci Ctr, Toronto, ON, Canada

[15] Univ Ottawa, Dept Neurol, Ottawa, ON, Canada

[16] Univ Saskatchewan, Dept Med Imaging, Saskatoon, SK, Canada

[17] London Hlth Sci Ctr, Dept Clin Neurol Sci, London, ON, Canada

[18] Dalhousie Univ, Dept Radiol, Halifax, NS, Canada

[19] Beaumont Hosp, Dept Neuroradiol, Dublin 9, Ireland

[20] Beaumont Hosp, Dept Geriatr & Stroke Med, Dublin 9, Ireland

[21] Royal Coll Surgeons Ireland, Dublin 2, Ireland

[22] Univ Pittsburgh, Dept Neurol, Med Ctr, Pittsburgh, PA 15260 USA

[23] Univ Pittsburgh, Med Ctr, Dept Neurosurg, Pittsburgh, PA 15260 USA

[24] Abington Mem Hosp, Inst Neurosci, Abington, PA 19001 USA

[25] Temple Univ, Dept Neurol, Philadelphia, PA 19122 USA

[26] Temple Univ, Dept Neurosurg, Philadelphia, PA 19122 USA

[27] Temple Univ, Dept Radiol, Philadelphia, PA 19122 USA

[28] Univ Tennessee, Acute Stroke Serv, Chattanooga, TN USA

[29] Erlanger Hosp, Dept Radiol, Chattanooga, TN USA

[30] Colorado Neurol Inst, Englewood, CO USA

[31] Yonsei Univ, Coll Med, Dept Neurol, Samsung Med Ctr, Seoul, South Korea

[32] Yonsei Univ, Coll Med, Dept Neurol, Seoul, South Korea

[33] Keimyung Univ, Dept Neurol, Dongsan Med Ctr, Taegu, South Korea

[34] Royal Victoria Hosp, Dept Neuroradiol, Belfast BT12 6BA, Antrim, North Ireland

[35] Med Univ S Carolina, Dept Neurol, Charleston, SC USA

来源：

NEW ENGLAND JOURNAL OF MEDICINE | 2015年 / 372卷 / 11期

关键词：

TISSUE-PLASMINOGEN-ACTIVATOR; INTERVENTIONAL MANAGEMENT; COMPUTED-TOMOGRAPHY; EARLY CT; REPERFUSION; RECANALIZATION; THERAPY; TIME; TRIALS; THROMBOLYSIS;

D O I：

10.1056/NEJMoa1414905

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

BACKGROUND Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. METHODS We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis). RESULTS The trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P<0.001). The primary outcome favored the intervention (common odds ratio, 2.6; 95% confidence interval, 1.7 to 3.8; P<0.001), and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group; P = 0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P = 0.75). CONCLUSIONS Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality.

引用

页码：1019 / 1030

页数：12

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