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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