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In this trial involving 543 patients with stroke due to occlusion of medium or distal vessels, endovascular treatment within 24 hours after the onset of symptoms was not effective in improving functional outcome at 90 days.

In 340 Chinese patients with basilar-artery occlusion, endovascular treatment resulted in better neurologic outcomes than medical care. Approximately one third of patients underwent intravenous thrombolysis.

In a trial conducted in China, patients with large cerebral infarctions as determined by imaging criteria within 24 hours after onset had better outcomes with endovascular therapy than with medical therapy alone.

Trials of the efficacy and safety of endovascular thrombectomy in patients with large ischemic strokes have been carried out in limited populations. We performed a prospective, randomized, open-label, adaptive, international trial involving patients with stroke due to occlusion of the internal carotid artery or the first segment of the middle cerebral artery to assess endovascular thrombectomy within 24 hours after onset. Patients had a large ischemic-core volume, defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower scores indicating larger infarction) or a core volume of at least 50 ml on computed tomography perfusion or diffusion-weighted magnetic resonance imaging. Patients were assigned in a 1:1 ratio to endovascular thrombectomy plus medical care or to medical care alone. The primary outcome was the modified Rankin scale score at 90 days (range, 0 to 6, with higher scores indicating greater disability). Functional independence was a secondary outcome. The trial was stopped early for efficacy; 178 patients had been assigned to the thrombectomy group and 174 to the medical-care group. The generalized odds ratio for a shift in the distribution of modified Rankin scale scores toward better outcomes in favor of thrombectomy was 1.51 (95% confidence interval [CI], 1.20 to 1.89; P<0.001). A total of 20% of the patients in the thrombectomy group and 7% in the medical-care group had functional independence (relative risk, 2.97; 95% CI, 1.60 to 5.51). Mortality was similar in the two groups. In the thrombectomy group, arterial access-site complications occurred in 5 patients, dissection in 10, cerebral-vessel perforation in 7, and transient vasospasm in 11. Symptomatic intracranial hemorrhage occurred in 1 patient in the thrombectomy group and in 2 in the medical-care group. Among patients with large ischemic strokes, endovascular thrombectomy resulted in better functional outcomes than medical care but was associated with vascular complications. Cerebral hemorrhages were infrequent in both groups. (Funded by Stryker Neurovascular; SELECT2 ClinicalTrials.gov number, NCT03876457.).

In acute ischemic stroke, thrombectomy with a stent retriever plus intravenous t-PA was more effective than t-PA in improving functional outcomes. At 90 days, 60% of patients in the intervention group were functionally independent, as compared with 35% in the control group. Intravenous tissue plasminogen activator (t-PA) administered within 4.5 hours after the onset of acute ischemic stroke improves outcomes. 1 – 3 However, intravenous t-PA has multiple constraints, including unresponsiveness of large thrombi to rapid enzymatic digestion, a narrow time window for administration, and the risk of cerebral and systemic hemorrhage. Among patients with occlusions of the intracranial internal carotid artery or the first segment of the middle cerebral artery (or both), intravenous t-PA results in early reperfusion in only 13 to 50%. 4 – 7 Neurovascular thrombectomy is a reperfusion strategy that is distinct from pharmacologic fibrinolysis. Endovascular mechanical treatments can remove large, proximal . . .

In this randomized trial involving patients with acute ischemic stroke with proximal anterior circulation occlusion, endovascular treatment with a Solitaire stent retriever was more effective than medical therapy alone in improving functional outcomes at 90 days. Recently completed prospective, randomized trials involving patients with acute stroke have consistently shown a clinical benefit for mechanical thrombectomy. 1 – 4 Our study, called the Randomized Trial of Revascularization with Solitaire FR Device versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset (REVASCAT), shares the following four features with the previously cited trials: enrollment limited to patients with imaging-based evidence of proximal occlusion of the M1 segment (main trunk) of the middle cerebral artery with or without concomitant occlusion of the internal carotid artery, imaging-based exclusion . . .

In a Chinese trial, endovascular thrombectomy at 6 to 24 hours led to more good outcomes than standard care but also to more cerebral hemorrhages. Approximately 20% of patients received intravenous thrombolysis.

In a trial involving patients with ischemic stroke due to medium-vessel occlusion, thrombectomy within 12 hours did not lead to a better functional outcome and lower mortality at 90 days than usual care.

Tenecteplase for thrombolysis in a 4.5-to-24-hour window did not improve disability outcomes at 90 days in patients with ischemic stroke who had been chosen on the basis of imaging. Most patients had endovascular thrombectomy.

In this trial involving patients with acute ischemic stroke treated with thrombolysis within 3 hours after symptom onset, the use of adjunctive intravenous argatroban or eptifibatide did not improve 90-day poststroke outcomes.