Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct

被引：4272

作者：

Nogueira, R. G. ^{[1
,2
]}

Jadhav, A. P. ^{[3
]}

Haussen, D. C. ^{[1
,2
]}

Bonafe, A. ^{[6
]}

Budzik, R. F. ^{[10
]}

Bhuva, P. ^{[12
]}

Yavagal, D. R. ^{[15
]}

Ribo, M. ^{[19
]}

Cognard, C. ^{[7
]}

Hanel, R. A. ^{[16
]}

Sila, C. A. ^{[11
]}

Hassan, A. E. ^{[13
]}

Millan, M. ^{[21
]}

Levy, E. I. ^{[22
]}

Mitchell, P. ^{[23
]}

Chen, M. ^{[24
]}

English, J. D. ^{[26
]}

Shah, Q. A. ^{[5
]}

Silver, F. L. ^{[34
,35
]}

Pereira, V. M. ^{[34
,35
,36
]}

Mehta, B. P. ^{[17
]}

Baxter, B. W. ^{[37
]}

Abraham, M. G. ^{[38
]}

Cardona, P. ^{[20
]}

Veznedaroglu, E. ^{[39
]}

Hellinger, F. R. ^{[18
]}

Feng, L. ^{[28
]}

Kirmani, J. F. ^{[40
]}

Lopes, D. K. ^{[25
]}

Jankowitz, B. T. ^{[4
]}

Frankel, M. R. ^{[1
,2
]}

Costalat, V. ^{[6
]}

Vora, N. A. ^{[10
]}

Yoo, A. J. ^{[12
]}

Malik, A. M. ^{[15
]}

Furlan, A. J. ^{[11
]}

Rubiera, M. ^{[19
]}

Aghaebrahim, A. ^{[16
]}

Olivot, J. -M. ^{[8
,9
]}

Tekle, W. G. ^{[13
]}

Shields, R. ^{[32
]}

Graves, T.

Lewis, R. J. ^{[14
,33
]}

Smith, W. S. ^{[27
]}

Liebeskind, D. S. ^{[29
,30
,31
]}

Saver, J. L. ^{[31
]}

Jovin, T. G. ^{[3
,14
]}

机构：

[1] Emory Univ, Sch Med, Marcus Stroke & Neurosci Ctr, Grady Mem Hosp, Atlanta, GA 30322 USA

[2] Emory Univ, Sch Med, Dept Neurol, Atlanta, GA USA

[3] Univ Pittsburgh, Dept Neurol, Stroke Inst, Med Ctr, Pittsburgh, PA 15260 USA

[4] Univ Pittsburgh, Dept Neurosurg, Med Ctr, Pittsburgh, PA USA

[5] Abington Hlth, Abington, PA USA

[6] Hop Gui De Chauliac, Dept Neuroradiol, Montpellier, France

[7] Univ Hosp Toulouse, Dept Diagnost & Therapeut Neuroradiol, Toulouse, France

[8] Univ Hosp Toulouse, Neuroimaging Ctr, Toulouse, France

[9] Univ Hosp Toulouse, Ctr Clin Investigat, Toulouse, France

[10] OhioHealth Riverside Methodist Hosp, Columbus, OH USA

[11] Univ Hosp Cleveland, Cleveland, OH USA

[12] Texas Stroke Inst, Dallas, TX USA

[13] Valley Baptist Med Ctr, Dept Neurosci, Harlingen, TX USA

[14] Berry Consultants, Austin, TX USA

[15] Univ Miami, Miller Sch Med, Dept Neurol & Neurosurg, Jackson Mem Hosp, Miami, FL 33136 USA

[16] Baptist Hlth, Jacksonville, FL USA

[17] Mem Reg Hosp, Hollywood, FL USA

[18] Florida Hosp, Orlando, FL USA

[19] Hosp Valle De Hebron, Stroke Unit, Barcelona, Spain

[20] Hosp Univ Bellvitge, Barcelona, Spain

[21] Univ Autonoma Barcelona, Dept Neurosci, Hosp Germans Trias & Pujol, Badalona, Spain

[22] SUNY Buffalo, Dept Neurosurg, Buffalo, NY USA

[23] Royal Melbourne Hosp, Dept Intervent Neuroradiol, Parkville, Vic, Australia

[24] Rush Univ, Med Ctr, Dept Neurol, Chicago, IL 60612 USA

[25] Rush Univ, Med Ctr, Dept Neurosurg, Chicago, IL 60612 USA

[26] Univ Calif San Francisco, Calif Pacific Med Ctr, San Francisco, CA 94143 USA

[27] Univ Calif San Francisco, Dept Neurol, San Francisco, CA USA

[28] Kaiser Permanente, Dept Neuroradiol, Los Angeles, CA USA

[29] Univ Calif Los Angeles, David Geffen Sch Med, Neurovasc Imaging Res Core, Dept Neurol, Los Angeles, CA 90095 USA

[30] Univ Calif Los Angeles, David Geffen Sch Med, Comprehens Stroke Ctr, Los Angeles, CA 90095 USA

[31] Univ Calif Los Angeles, David Geffen Sch Med, Los Angeles, CA 90095 USA

[32] Stryker Neurovasc, Fremont, CA USA

[33] Los Angeles Cty Harbor UCLA Med Ctr, Torrance, CA USA

[34] Univ Toronto, Univ Hlth Network, Toronto Western Hosp, Dept Med Imaging, Toronto, ON, Canada

[35] Univ Toronto, Univ Hlth Network, Toronto Western Hosp, Dept Surg, Toronto, ON, Canada

[36] Univ Toronto, Univ Hlth Network, Toronto Western Hosp, Dept Neurol, Toronto, ON, Canada

[37] Univ Tennessee, Dept Radiol, Erlanger Hosp, Chattanooga, TN USA

[38] Univ Kansas, Med Ctr, Dept Neurol, Kansas City, KS 66103 USA

[39] Capital Hlth Hosp, Ctr Neurosci, Trenton, NJ USA

[40] JFK Med Ctr, Edison, NJ USA

来源：

NEW ENGLAND JOURNAL OF MEDICINE | 2018年 / 378卷 / 01期

关键词：

MODIFIED RANKIN SCALE; ACUTE ISCHEMIC-STROKE; RANDOMIZED CONTROLLED-TRIAL; ENDOVASCULAR THERAPY; OCCLUSION; TIME; METAANALYSIS; REPERFUSION; ALTEPLASE; TISSUE;

D O I：

10.1056/NEJMoa1706442

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

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 or >= 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.)

引用

页码：11 / 21

页数：11

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