Even more benefit with endovascular treatment for patients with acute ischaemic stroke: MR CLEAN-LATE

Since 2015 endovascular treatment has been an established treatment for intracranial large artery occlusion up to 6 h after symptom onset or when the patient was last known well. 1 Saver JL Goyal M Van der Lugt A et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016; 316: 1279-1289 Crossref PubMed Scopus (1346) Google Scholar The effect of endovascular treatment within 6 h is strong; however, the timepoint when recanalisation therapy becomes ineffective varies between individuals, and some patients might benefit after 6 h. The DEFUSE-3 and DAWN trials tested endovascular treatment up to 16 h or 24 h after symptom onset in patients selected using clinical criteria and perfusion imaging (to identify ischaemic core and tissue-at-risk volumes within strict limits), and showed benefit within these strict criteria. 2 Albers GW Marks MP Kemp S et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018; 378: 708-718 Crossref PubMed Scopus (2794) Google Scholar , 3 Nogueira RG Jadhav AP Haussen DC et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018; 378: 11-21 Crossref PubMed Scopus (3195) Google Scholar On this basis, endovascular treatment was extended for clinical use beyond 6 h after stroke for patients meeting the DEFUSE-3 and DAWN clinical and perfusion imaging criteria. However, the large treatment benefit in these late-treatment-window trials, despite strict selection criteria, suggested that more patients might benefit from endovascular treatment in the late window. Because perfusion imaging is not universally available and definitions of infarct core and tissue-at-risk are inconsistent and not easy to use in emergency settings, identification of more pragmatic easy-to-interpret widely available imaging selection methods could make endovascular treatment accessible to many more late-presenting patients worldwide. Endovascular treatment versus no endovascular treatment after 6–24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trialIn this study, endovascular treatment was efficacious and safe for patients with ischaemic stroke caused by an anterior circulation large-vessel occlusion who presented 6–24 h from onset or last seen well, and who were selected on the basis of the presence of collateral flow on CTA. Selection of patients for endovascular treatment in the late window could be primarily based on the presence of collateral flow. Full-Text PDF