MD Conference Express ISC 2013 - (Page 16)
CLINICAL TRIAL HIGHLIGHTS
Brain Imaging Does Not Help Identify
Patients Who May Benefit From
Endovascular Treatments for Acute
Ischemic Stroke
Written by Mary Beth Nierengarten
Peer-Reviewed
Highlights From
Patients who undergo neuroimaging to identify a favorable penumbral pattern do not benefit
from endovascular treatment any differently than people with a nonpenumbral pattern when
treated within 8 hours of an acute ischemic stroke, according to Chelsea S. Kidwell, MD,
Georgetown University, Washington, DC, USA, who reported results of the Mechanical Retrieval
and Recanalization of Stroke Clots Using Embolectomy trial [MR RESCUE; Kidwell CS et al.
N Engl J Med 2013]. The results also showed that, regardless of penumbral pattern, clinical and
imaging outcomes were no different between patients undergoing embolectomy versus those
who received standard medical care for acute ischemic stroke.
MR RESCUE was a Phase 2b, multicenter, randomized, controlled trial that was undertaken
to test the hypothesis that the presence of substantial penumbral tissue identifies patients most
likely to respond to mechanical embolectomy for acute ischemic stroke. A secondary hypothesis
tested was that embolectomy would result in improved functional outcomes compared with
standard medical care.
In the study, 118 patients were randomly assigned to embolectomy (n=64) or standard care (n=54)
within 8 hours of the onset of symptoms of a large-vessel, anterior-circulation ischemic stroke. All
patients were aged 18 to 85 years, had a National Institute of Health Stroke Scale (NIHSS) score >6, and
had a premorbid modified Rankin Scale (mRS) score of 0 to 2. Patients were excluded from the study
if they were pregnant or had an NIHSS score >30, acute intracranial hemorrhage, rapidly improving
symptoms, refractory iodine allergy, proximal carotid stenosis >67% or dissection, international
normalized ratio >3.0 or partial thromboplastin time >3 times the normal, or renal failure.
Prior to randomization, all patients underwent pretreatment multimodal MRI or CT
neuroimaging and were then stratified according to whether they had a favorable penumbral pattern
(ie, substantial salvageable tissue and small infarct core) or a nonpenumbral pattern (ie, large core,
or small or absent penumbra). Of the 118 patients, 58% had a favorable penumbral pattern.
In the embolectomy group, 34 had a favorable penumbral pattern and 30 had a nonpenumbral
pattern. In the standard-care group, 34 patients had a favorable penumbral pattern and 29 had a
nonpenumbral pattern.
The study found no difference in the benefit of endovascular therapy based on penumbral
pattern, with a statistically insignificant mean difference of 0.88 between patients with a favorable
penumbral pattern versus those with a nonpenumbral pattern based on a 90-day mRS score
comparing embolectomy with standard care (p=0.14; Table 1).
Table 1. Primary Outcome Analyses
E/Pen
n=34
Mean (95% CI) Day
90 mRS
S/Pen
n=34
E/Non-Pen
n=30
S/Non-Pen
n=20
3.9
(3.3–4.4)
3.4
(2.8–4.0)
4.0
(3.4–4.6)
4.4
(3.6–5.2)
p Value
0.14
E=embolectomy; Pen=favorable penumbral pattern; mRS=modified Rankin Scale; S=standard care.
There was no difference in clinical or imaging outcomes between patients treated by
embolectomy versus standard care regardless of imaging pattern. Among all patients, no difference
was found in the 90-day mRS score between embolectomy and standard care (3.9 vs 3.9; p=0.99),
and the 90-day mortality (21%) and symptomatic intracranial hemorrhage rate (4%) did not differ
between groups.
16
April 2013
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Table of Contents for the Digital Edition of MD Conference Express ISC 2013
MD Conference Express ISC 2013
Contents
Defending the Stroke Guidelines
Stroke Update: An Overview of What Is Going on in the Area of Stroke
Brain Imaging Does Not Help Identify Patients Who May Benefit From Endovascular Treatments for Acute Ischemic Stroke
MISTIE II Trial: 365-Day Results Demonstrate Improved Outcomes and Cost Benefit
Addition of AMPLATZER PFO Occluder to Medical Therapy Is Beneficial in Patients With Cryptogenic Stroke and PFO
Intraoperative CT-Guided Endoscopic Surgery for ICH [ICES]
The EMBRACE Trial: Prolonged Ambulatory Cardiac Monitoring Improves the Detection and Treatment of Atrial Fibrillation in Patients With Cryptogenic Stroke
DP-b99 Does Not Improve Recovery Following Acute Ischemic Stroke
The Secondary Prevention of Small Subcortical Strokes Trial: Blood Pressure Intervention Results
Final Results of the Solitaire FR Thrombectomy for Acute Revascularization: The STAR Trial
Clopidogrel Plus Aspirin Reduces Risk of Recurrent Stroke: The CHANCE Trial
Reversal of Chronic Hypoperfusion to Improve Cognitive Function: The RECON Trial
Cardioembolic Stroke
IMS III
Novel Anticoagulants in Vascular Neurology Practice
Wake-Up Stroke
Virtual Reality in Stroke Rehabilitation
Reward Improves Long-Term Retention of a Motor Memory Through Induction of Offline Memory Gains
MD Conference Express ISC 2013
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