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Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke (ESCAPE)
RFS Journal Primer
BOTTOM LINE • Rapid endovascular treatment with careful selection of patients based on speci:ic imaging criteria
leads to improved functional outcomes and reduced mortality. MAJOR POINTS • Randomized trial comparing thrombectomy with current standard of care versus current standard
of care alone. • Careful selection of patients by CT/CTA imaging criteria, including small infarct core, moderate-‐to-‐
good collateral :low and visualized proximal artery occlusion in the anterior circulation. • Trial centers had highly ef:icient, rapid work:low procedures to achieve recanalization. • Signi:icant bene:it demonstrated with improved functional independence at 90 days and reduced
mortality in the intervention group.
CRITICISM
• Early study termination leads to risk of bias in overestimating magnitude of treatment bene:it.
• Selected endovascular centers capable of highly ef:icient work:low and expertise which may not be widespread currently
Quick Summary
Randomized, open-‐label, controlled trial with blinded outcome evaluation • 315 patients (165 received intervention with standard care, 150 standard care
alone) • Time range: Feb 2013-‐ Oct 2014; terminated early due to ef:icacy
INCLUSION CRITERIA • Patients presenting with proximal anterior circulation acute ischemic stroke
with small core infarct on multiphase CTA (ASPECT 6-‐10) • Functional independence prior to stroke (Barthel Index >90) • Presenting within 12 hours of symptom onset • Moderate-‐to-‐good collateral circulation (:illing of 50% or more of the MCA pial
arterial circulation on CTA) EXCLUSION CRITERIA • Functional dependence prior to stroke (Barthel Index <90) • Delayed presentation (>12 hrs after symptom onset) • Not meeting aforementioned imaging inclusion requirements
Study design
• To evaluate the bene:it of rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke selected by imaging :indings on CT/CTA.
• Selection criteria speci:ically include a small infarct core on multiphase CTA, a proximal intracranial arterial occlusion, and moderate-‐to-‐good collateral circulation.
Purpose
• Intervention group underwent both mechanical thrombectomy and standard care (including IV thrombolysis if patient presented within 4.5 hours of symptom onset).
• Cerebral angiography and thrombectomy, using an array of different devices, were performed.
• Retrievable stents were recommended to be used where possible (86%). Additionally, suction retrieval of thrombus if present in ICA was also recommended.
Interven7on
Outcome
• Primary outcome measure was functional independence de:ined as a score of 0-‐2 on the modi:ied Rankin scale at 90 days. Functional independence was signi:icantly increased in the intervention group (51.6% vs 23.1%, P<0.001).
• Mortality was signi:icantly reduced in the intervention group (10.4% vs 19.0%, P=0.04). • Symptomatic intracranial hemorrhage was not signi:icantly different between intervention vs
control arms (3.6% vs 2.7%, P>0.05).
Credits
SUMMARY BY: Sean A. Kennedy MD, PGY1 Department of Diagnostic Radiology University of Toronto Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, CouQs SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD; ESCAPE Trial Inves7gators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015 Mar 12;372(11):1019-‐30.
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