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Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke

OPEN The New England journal of medicine | 9 Feb 2013

JP Broderick, YY Palesch, AM Demchuk, SD Yeatts, P Khatri, MD Hill, EC Jauch, TG Jovin, B Yan, FL Silver, R von Kummer, CA Molina, BM Demaerschalk, R Budzik, WM Clark, OO Zaidat, TW Malisch, M Goyal, WJ Schonewille, M Mazighi, ST Engelter, C Anderson, J Spilker, J Carrozzella, KJ Ryckborst, LS Janis, RH Martin, LD Foster and TA Tomsick
Abstract
Background Endovascular therapy is increasingly used after the administration of intravenous tissue plasminogen activator (t-PA) for patients with moderate-to-severe acute ischemic stroke, but whether a combined approach is more effective than intravenous t-PA alone is uncertain. Methods We randomly assigned eligible patients who had received intravenous t-PA within 3 hours after symptom onset to receive additional endovascular therapy or intravenous t-PA alone, in a 2:1 ratio. The primary outcome measure was a modified Rankin scale score of 2 or less (indicating functional independence) at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). Results The study was stopped early because of futility after 656 participants had undergone randomization (434 patients to endovascular therapy and 222 to intravenous t-PA alone). The proportion of participants with a modified Rankin score of 2 or less at 90 days did not differ significantly according to treatment (40.8% with endovascular therapy and 38.7% with intravenous t-PA; absolute adjusted difference, 1.5 percentage points; 95% confidence interval [CI], -6.1 to 9.1, with adjustment for the National Institutes of Health Stroke Scale [NIHSS] score [8-19, indicating moderately severe stroke, or ≥20, indicating severe stroke]), nor were there significant differences for the predefined subgroups of patients with an NIHSS score of 20 or higher (6.8 percentage points; 95% CI, -4.4 to 18.1) and those with a score of 19 or lower (-1.0 percentage point; 95% CI, -10.8 to 8.8). Findings in the endovascular-therapy and intravenous t-PA groups were similar for mortality at 90 days (19.1% and 21.6%, respectively; P=0.52) and the proportion of patients with symptomatic intracerebral hemorrhage within 30 hours after initiation of t-PA (6.2% and 5.9%, respectively; P=0.83). Conclusions The trial showed similar safety outcomes and no significant difference in functional independence with endovascular therapy after intravenous t-PA, as compared with intravenous t-PA alone. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT00359424 .).
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Concepts
Rehabilitation medicine, Barthel scale, Thrombolysis, Disability, Plasmin, Modified Rankin Scale, Tissue plasminogen activator, Stroke
MeSH headings
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