1. Natalie Hendon MD Virginia Mason Medical Center Seattle, WA 2/21/2015
Updates in Stroke
Natalie Hendon MD
Virginia Mason Medical Center
Seattle, WA
2/21/2015

2. Learning Objectives Review stroke burden
Discuss early dual antiplatelet therapy in minor CVA or TIA
Use of SSRIs as potential neuromodulators for improved motor function in stroke patients at 3 months
Optimal treatment of stroke or TIA due to intracranial stenosis
Identify components of aggressive medical management in secondary stroke prevention
New directions in emergent treatment of acute ischemic stroke

3. Outline CHANCE trial FLAME trial
Early short-term dual antiplatelet therapy
FLAME trial
Fluoxetine for motor recovery after ischemic stroke
Intracranial stenosis – optimal treatment
SAMMPRIS trial and WASID trial
Updates in secondary prevention of stroke
Aggressive medical management
Statin usage
Intra-arterial treatment for acute ischemic stroke
MR CLEAN
ESCAPE
EXTEND-IA

4. Epidemiology and Burden of Stroke
800,000 strokes annually in the US
600K are new CVA, 200K are recurrent CVA
Stroke is the leading cause of chronic disability in the US
One of the leading causes of death, with 130K-140K stroke deaths annually in the US
Heterogenous disease – primary hemorrhage (10%), subarachnoid hemorrhage (3%), ischemia (87%), venous thrombosis, and more
Varying risk factors

5. Ischemic Stroke and TIA
Patients with ischemic stroke and TIA are at high risk for recurrent events, especially in the first few days
Risk of CVA after TIA at 2 days is %
Risk of CVA after TIA at 90 days is 9-17%
ABCD2 score to identify patients at higher risk of stroke
Patient age, BP, DM, type of symptoms, duration of symptoms
High risk scores (>5 points) have 12% risk of recurrent ischemic event in 1 week

7. CHANCE Clopidogrel in High-Risk Patients with Acute Nondisabling Cereberovascular Events
Rationale: Stroke is common during the first few weeks after a TIA or minor ischemic stroke. Dual antiplatelet therapy may provide additional benefit.
Methods:
Randomized, double blind, placebo controlled trial at 114 centers in China
5170 patients within 24 hrs after onset of high-risk TIA or minor ischemic stroke
Randomized to combination therapy with clopidogrel and aspirin OR to placebo plus aspirin
Primary outcome was stroke during 90 days

8. CHANCE: Inclusion Criteria
Age 40 or older
Diagnosis of acute minor ischemic CVA
NIHSS 3 or less at time of randomization OR
Diagnosis of TIA
Focal brain ischemia with resolution of symptoms within 24 hrs, plus moderate to high risk of stroke recurrence (>4 on ABCD)
Ability to start study drug within 24 hrs after symptom onset
ABCD: Risk of stroke on basis of age, BP, clinical features, duration of TIA, diabetes presence, with scores 0-7 with higher scores indicating greater short term risk

9. CHANCE: Exclusion Criteria
Hemorrhage, vascular malformation, tumor abscess, other major nonischemic brain disease
Isolated sensory symptoms
Isolated visual changes
Isolated dizziness or vertigo without evidence of acute infarct on baseline imaging
Score of >2 on modified Rankin scale prior to event
NIHSS of 4 or more
Clear indication for anticoagulation
Presumed cardioembolic source
Contraindication to clopidogrel or aspirin
History of intracranial hemorrhage
Others, standard tPA exclusion criteria
Modified Rankin scale ranging from 0 (no symptoms) to 6 (death)

10. CHANCE trial 41,561 pts screened 5170 pts enrolled
2548 clopidogrel-ASA
2586 to ASA
Median age 62
33.8% were women
65.7% with HTN
21.1% with DM
43% smoking history
27.9% with TIA, 72% CVA
Dual antiplatelet therapy vs aspirin alone for 21 days, followed by aspirin OR Plavix
No significant differences between treatment groups for any characteristic
Data are only for the 1445 pts who had TIA
Most had MINOR STROKE

11. CHANCE: Outcome definitions
Primary efficacy outcome was new stroke event (ischemic OR hemorrhagic) at 90 days
Primary safety outcome was moderate to severe bleeding event
Key secondary efficacy outcomes
New clinical vascular event (CVA, MI, vascular death due to stroke, MI, CHF, PE, sudden death, arrhythmia)

12. CHANCE: Results
Stroke occurred in 8.2% in the clopidogrel-aspirin group, and 11.7% in the aspirin group.
Hazard ratio 0.68, 95% confidence interval 0.57 to 0.81, P<0.001
Composite outcome of vascular events in clopidogrel-aspirin group 8.4% and 11.9% in aspirin group
TIA in 1.5% in clopidogrel-aspirin group and 0.2% in aspirin group
Moderate or severe hemorrhage occurred in 7 pts (0.3%) in clopidogrel-aspirin group and in 8 (0.3%) in the aspirin group (P=0.73)

14. CHANCE: Conclusions
Conclusions: Combination clopidogrel and aspirin is superior to aspirin alone for reducing risk of stroke in the first 90 days and does not increase risk of hemorrhage
Within 24 hrs of symptom onset
Dual antiplatelet therapy 21 days followed by aspirin or Plavix alone

15. CHANCE: Caveats
Population at very high risk for recurrent stroke and at low risk for hemorrhage
Study conducted entirely in China
Lower rates of treatment for HTN, DM and HL
Higher incidence of large artery intracranial atherosclerosis
Higher prevalence of genetic polymorphisms that affect the metabolism of clopidogrel

16. CHANCE: Take-Home Message
Dual antiplatelet therapy for 21 days with onset within 12 hrs of TIA or minor ischemic stroke reduces chance of recurrent ischemia without change in bleeding risk

17. Depression and Stroke
Mean prevalence of post-stroke depression is 20% among patients receiving care for stroke
Post-stroke major depression has mean duration of 9 months
Significant minority continue to have depression 3 years out
Several trials have evaluated treatment of depression post-stroke
Some trials have suggested improved functional outcome

18. FLAME Trial

19. FLAME
Rationale: Hemiparesis is common after stroke and prior small trials suggest that fluoxetine enhances motor recovery. Study to investigate whether fluoxetine enhances motor recovery if given soon after ischemic stroke in pts with motor deficits.
Methods:
Double-blind, placebo controlled trial
9 stroke centers in France with ischaemic CVA and hemiparesis
Fluoxetine 20 mg daily or placebo for 3 months starting 5-10 days after stroke
Primary outcome change of motor symptoms between day 0 and 90
Fugl-Meyer motor scale (FMMS) scores 55 or less
Ages eligible for inclusion

20. FLAME: Background
Recovery of neurological function is associated with intracerebral reorganization
Various interventions after CVA have been shown to modulate brain plasticity after CVA
Amphetamines show enhanced recovery in animal models
BZDs and neuroleptics reduce recovery in these models
SSRIs have shown acute neuroprotective action on ischemic brain and promote hippocampal neurogenesis
Functional MRI studies show that single doses of fluoxetine and paroxetine overactivate motor cortices compared with placebo in pts with and without CVA

21. FLAME: Inclusion Criteria
Acute ischaemic CVA within prior 5-10 days that caused hemiparesis/hemiplegia
9 stroke units in France
Age 18-55
Fugl-Meyer motor scale 55 or less at baseline
Fugl-Meyer motor scale (FMMS) – standardized scale used to define motor function after stroke, assess voluntary limb movement, minimum score 0 (flaccid hemiplegia) maximum score 100 (normal movement; 66 points for upper limb and 34 pts for lower limb
Excellent intra-rater and inter-rater reliability and validity

22. FLAME: Exclusion Criteria
Severe post-stroke disability NIHSS >20
Substantial premorbid disability
Pre-existing deficit such as residual motor defict from prior CVA, comprehension deficits, severe aphasia
Diagnosis of depression
On antidepressants, MAOIs, neuroleptics, or BZDs during month prior to inclusion
Impending carotid endarterectomy
Pregnancy
Major disease processes that would prevent f/u

23. FLAME
Primary outcome was mean change in FMMS between day 0 and 90 as assessed by physiotherapist
Secondary endpoints were NIHSS, modified Rankin Scale and MADRS
MADRS: Montgomery-Asherg Depression Rating Scale

24. FLAME 118 patients, 6 lost 57 fluoxetine, 56 placebo
Well balanced baseline, demographic and stroke severity characteristics
Mean age and h/o CVA higher in fluoxetine group
FMMS score at day 0 higher in fluoxetine group
NIHSS, mRS and MADRS scores similar at day 0
All patients underwent physiotherapy

25. FLAME: Results
Mean progression in FMMS total score from baseline to day 90 was significantly higher in fluoxetine group than in placebo group
Significant for both upper and lower limb scores

26. FLAME: Results NIHSS at day 90 did not differ
Motor component score significantly higher in fluoxetine group
Adjusted mean MADRS change was significantly lower in fluoxetine group than placebo
Frequency of depression significantly higher in placebo
FMMS change signifiantly greater in fluoxetine group even after adjusting for depression

27. FLAME: Caveats
Small number of patients enrolled (but larger than prior trials)
Pts selected for motor deficit and thus do not represent all CVA deficits
Treatment stopped at 90 days; long-term outcome unknown

28. FLAME: Take-Home
Fluoxetine 20 mg started in 5-10 days post stroke with motor deficits resulted in improvement in motor recovery compared to placebo when tested with FMMS, but not when tested with NIHSS
mRS showed more independent patients in fluoxetine group than placebo
Major role of motor function recovery in global recovery and return to independent activities

29. Intracranial Stenosis and Stroke
Intracranial stenosis causes 8-10% of ischemic strokes in the USA
Risk of stroke especially high in patients with recent stroke or TIA and severe arterial stenosis (70-99%)
Treatment options have changed over time due to release of results of major multicenter randomized stroke prevention trials

30. WASID Trial: Comparison of Warfarin and Aspirin for Symptomatic Intracranial Arterial Stenosis

31. WASID: Summary
Warfarin used to be used preferentially instead of aspirin for treatment of atherosclerotic intracranial arterial stenosis.
569 patients were randomized after found by angiogram to have 50-99% stenosis of a major intracranial artery to receive warfarin or aspirin
Trial stopped early due to safety for patients assigned to warfarin, with higher rates of death, major hemorrhage, and MI
Primary endpoint of ischemic stroke occurred in 22.1% of aspirin patients and 21.8% of warfarin pts
Aspirin should be used instead of warfarin in patients with intracranial arterial stenosis

32. SAMMPRIS Trial: Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis

33. SAMMPRIS: Rationale
Designed to assess whether percutaneous transluminal angioplasty and stenting (PTAS) with Wingspan stent system plus aggressive medical treatment is more effective than aggressive medical treatment alone in high risk patients
Patients with recent (<30 days) TIA or non-disabling CVA attributed to angiographically verified severe intracranial stenosis

34. SAMMPRIS: Early results
Early results of the SAMPRIS trial showed by 30 days 14.7% of patients in the stenting group and 5.8% of pts in medical group had died or had a stroke
 Trial stopped early
Patients continued to be followed to establish whether early benefit in medical group would persist over time, or whether they would have higher incidence of later strokes

35. 1 year rate of CVA, ICH or death from vascular causes other than CVA
SAMMPRIS
The rate of stroke in the medical management group was much lower than expected
30 day rate of CVA or death
1 year rate of CVA, ICH or death from vascular causes other than CVA
WASID
10.7%
25%
SAMMPRIS
5.8%
12.2%
Patients in the WASID trial with same entry criteria who were treated with warfarin or aspirin and standard management of risk factors had 30 day rate of stroke or death of 10.7% and 1 year rate of primary end point of 25%
Patients in SAMMPRIS (medical management group) had 5.8% and 12.2%

36. SAMMPRIS: Aggressive Medical Management
Aspirin 325 mg daily
Clopidogrel 75 mg daily for 90 days
Management of primary risk factors (HTN and elevated LDL)
SBP <140 or <130 if comorbid DM
Drug from each major class of antihypertensives
LDL <70
Rosuvastatin
Management of secondary risk factors (DM, elevated non-HDL, smoking, obesity, lack of exercise) with help of lifestyle modification program

37. BP management: Goal SBP <140, with 30 day follow ups and adding on additional medications (ACE I lisinopril, thiazide chlorthalidone, ultimately additional medication atenolol, felodipine or spironolactone, then hydralazine, candesartan, clonidine)

38. SAMMPRIS: Hyperlipidemia Mangament
Goal LDL <70, treatment with rosuvastatin OR increase dose of pt’s other statin

39. SAMMPRIS: Lifestyle modification program
Delivered by coach who contacted patients by telephone every 2 weeks for the first 3 months, then monthly
Baseline assessment of risk factors
Formulation of action plan with focus on exercise, nutrition, weight, tobacco cessation
Follow up counseling sessions to help acquire skills, motivation and support to adhere to plan

40. Significant improvement in vascular risk factors with aggressive medical management: SBP 10 point drop, LDL point drop, HgbA1c drop in medically managed group but not PTAS group, BMI no change, drop in smoking (more so in MMG), increase in moderate or vigorous exercise

41. SAMMPRIS vs WASID Vascular risk factors at trial entry
Similar rates for hypertension, history of/current smoking
SAMMPRIS had higher rates of DM and hyperlipidemia, higher proportion starting out already on antithrombotic tx
WASID
SAMMPRIS
HTN
84%
89% DM
38%
46%
Hyperlipidemia
71%
89.5%
History of/current smoking
65%
64%
Antithrombotic tx
53%
63%

42. SAMMPRIS Trial: Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis

43. SAMMPRIS Follow Up Median follow up of 32 months
15% of medical group and 23% of stenting group had stroke or death
Occurrence of adverse effects (any stroke, major hemorrhage) was higher in stenting group
 Medical management superior to stenting

44. SAMMPRIS
Aggressive medical management may help address vascular risk factors more readily and may help prevent future strokes
In patients with intracranial stenosis
Dual antiplatelet treatment for 30 days post TIA/CVA
Following trial’s protocol to lowering BP and LDL cholesterol

45. SAMMPRIS: Take Home
For patients with recently symptomatic severe (70-99%) intracranial stenosis, aggressive medical management is superior to stenting
Aggressive medical management practices can lower risk of future stroke

46. Cholesterol Management in Stroke
Statins have been shown to reduce the risk of stroke among patients with CAD and those at increased risk for cardiovascular disease
Prior studies (meta-analysis 90,000 pts) have shown that reduction in stroke risk was primarily related to extent to which LDL was lowered
SPARCL trial designed to determine whether daily dose of 80 mg atorvastatin would reduce risk of stroke in pts with NO known CAD who had had a CVA or TIA in the previous 6 months

48. SPARCL: Baseline Characteristics 2365 pts in atorvastatin group
2366 pts in placebo group
Entry event was CVA in about 70% in both, TIA in about 30% in both. Hemorrhagic CVA accounted for 2% in both
Time since entry about 85 days
Similar risk factors
Similar concomitant therapy for risk factors
LDL about 133, HDL 50, TG 143-4

49. SPARCL: Decreased risk of fatal or nonfatal stroke or TIA with Atorvastatin

50. SPARCL: Decreased risk of any coronary and cardiovascular events with Atorvastatin

51. AHA/ASA Scientific Advisory 2013: Statins

52. AHA: High/Moderate/Low Intensity
Atorvastatin 80 mg: evidence from 1 RCT only .If adverse effects, downtitration to 40.

53. AHA: Secondary Prevention and Statins
Women and men with clinical atherosclerotic cardiovascular disease (ACS, MI, angina, coronary revascularization, CVA or TIA presumed to be of atherosclerotic origin, and PVD or revascularization) are at increased risk of recurrent ASCVD and ASCVD death.
An extensive body of evidence demonstrates that high-intensity statin therapy reduces ASCVD events more than moderate-intensity statin therapy in individuals with clinical ASCVD.
No evidence to support titrating meds to goal LDL, as clinical trials were mainly fixed dose

55. AHA Recommendations in Stroke/TIA
Patients 75 and younger, initiate high intensity statin therapy
Patients older than 75, initiate moderate intensity statin therapy
Counsel both on healthy lifestyle habits

56. Recent Advances: Intra-arterial Treatment for Acute Ischemic Stroke MR CLEAN (the Netherlands) ESCAPE (Canada) EXTEND-IA (Australia)

57. Argument for Intra-Arterial Treatment
IV alteplase within 4.5 hours after onset of symptoms is the only reperfusion therapy with proven efficacy in patients with acute ischemic stroke
Narrow therapeutic window
Contraindications including surgery, coagulation abnormalities, h/o ICH
Less effective at opening proximal occlusions
>1/3 of acute anterior circulation CVA
Early recanalization after IV alteplase is seen in only 1/3 of patients with occlusion of the ICA terminus
 poor prognosis

58. Among pts with a proximal vessel occlusion in the anterior circulation, 60-80% die within 90 days after stroke onset, or do not regain functional independence despite alteplase treatment.9
Recent studies have shown superiority of retrievable stents over the prior generation of thrombectomy devices.10

59. Intra-arterial therapy options
Locally delivered thrombolytic agents with clot retrieval
Thrombectomy with mechanical devices

61. MR CLEAN: Objective
Is intraarterial treatment plus usual care more effective than usual care alone
Patients with proximal arterial occlusion in the anterior cerebral circulation
Treatment intraarterially within 6 hours after symptom onset

62. MR CLEAN: Design
Phase 3, multicenter clinical trial, randomized, open-label treatment, blinded end-point evaluation
Patients with acute ischemic stroke and proximal intracranial anterior ciculation occlusion on vessel imaging
Intraarterial thrombolysis, mechanical treatment, or both plus usual care (which could include IV altepase)

63. MR CLEAN: Inclusion Criteria
16 centers in the Netherlands
Age 18-no upper limit
Acute ischemic stroke of proximal anterior circulation confirmed on vessel imaging (CTA or MRA or DSA)
NIHSS 2 or higher
Patients with additional extracranial ICA occlusion or dissection left to judgment of treating physician
Distal ICA, M1 or M2, or A1 or A2

64. MR CLEAN
502 patients
Similar age (mid-60s), gender distribution, NIHSS, associated risk factors, blood pressure, prestroke modified Rankin score
Similar time from stroke onset to start of IV alteplase (85-87 minutes)
Similar distribution of clot
Higher extracranial ICA occlusion in intervention group
Time from stroke onset to randomization about 200 minutes
Time from stroke onset to groin puncture 260 minutes

65. MR CLEAN: Intervention
Arterial catheterization with a microcatheter to the level of occlusion and delivery of a thromboylitic agent, mechanical thrombectomy, or both
Use of alteplase or urokinase
Restricted total dosage if IV-alteplase was given
Mechanical treatment: thrombus retraction, aspiration, wire disruption, use of retrievable stent
Devices approved by FDA or CE and approved by steering committee
1+ members of each intervention team had to have completed at least 5 full procedures with a particular device

66. MR CLEAN: Outcome
Primary outcome – score on modified Rankin scale at 90 days
Secondary outcomes included:
NIHSS at 24 hrs and at 5-7 days or discharge if sooner
ADLs as measured with Barthel index
Health related quality of life with EuroQol Group 5-Dimension Self-Report Questionaire at 90 days
Imaging outcomes: arterial recanalization mesausred with CTA or MRA at 24 hrs, final infarct volume on noncontrast head CT at 5-7 days
Safety outcomes: hemorrhagic complications, progression of ischemia, new ischemic CVA in new vascular territory, death
Modified Ranking scale is 7 point scale ranging from 0 (no symptoms) to 6 (death
Score of 2 or less indicates functional independence

67. MR CLEAN: Results
Intraarterial therapy with or without mechanical thrombectomy performed in 196 of the 233 patients in the intervention group (84.1%
General anesthesia used in 37.8%
Second revascularization procedure (acute cervical carotid stenting) in 12.9%
Mechanical treatment in 195 of the 233 pts (83.7%)
Retrievable stents in 190 patients (81.5%)
Other devices used in 5 pts (2.1%)
Intraarterial thrombolytic agents used as monotherapy in 1 of the 233 pts (0.4%)
No intervention in 37 pts (15.9%

68. Primary outcome = score on mRS at 90 days
Shift in distribution in favor of intervention, adjusted common odds ratio of 1.67
Secondary outcomes – all clinical and imaging secondary outcomes favored the intervention
NIHSS after 5-7 days was 2.9 points less on average in the intervention group
Absence of residual occlusion at the target site was more common in the intervention group
Between group difference volume of infarct on CT favored the intervention group
Good reperfusion was achieved in 115 of the 196 (58.7% of the intervention group

69. Significant difference in intervention group and control in distribution of scores in an analysis with univariable ordinal regression (1.66) and after adjustment of treatment for age, NIHSS, stroke onset to randomization time, status of any prior CVA, afib, DM, occlusion of ICA terminus (1.67)
0 – no symptoms
1 – no clinically significant disability
2 – slight disability (able to look after own affairs without help but unable to do all prior activities
3 – moderate disability (requires some help but can walk unassisted)
4 – moderately severe disability (unable to attend to bodily needs or walk without assistance)
5 – severe disability (requires continuous nursing care/attention)
6 - death

70. No significant between-group difference in serious adverse effects in 90-day follow up period
13/233 pts (5.6% in intervention group had clinical signs of a NEW ischemic CVA in a different vascular territory within 90 days, and only 1/267 (0.4%) in the control group did
No significant difference in mortality at 7, 30, 90 days of follow up
Procedure related complications included embolization into new vascular territories outside the target downstream in 20/233 (8.6%), procedure related dissection in 4 (1.7%) and vessel perforations in 2 (0.9%)

71. MR CLEAN – Conclusions and Discussion
Patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion of the anterior circulation have BENEFIT with respect to FUNCTIONAL RECOVERY when intraarterial treatment is given within 6 hrs of onset
 Clinically significant increase in functional independence in daily life by 3 months, without increase in mortality

72. MR CLEAN and prior IA trials
Prior trials have not shown a benefit to IA treatment
Timing: Interventional Management of Stroke (IMS) III trial gave IV alteplase plus IA treatment with randomization 40 minutes after start of IV alteplase (about 120 minutes after IV alteplase
This may have led to inclusion of more pts with favorable response to IV alteplase than MR CLEAN
Proximal occlusion vs more distal: IMS III and SYNTHESIS Expansion trial did not require radiographically proven intracranial occlusion
Presence of proximal arterial occlusion uncertain in 47% of the study population
Possible that intraarterial intervention will not alter natural history of ischemic CVA in the absence of proximal arterial occlusion

73. MR CLEAN Caveats
9% of pts in the intervention group had embolizationn into new vascular territories
13% underwent simultaneous second revascularization procedure (acute cervical carotid stent)
Unclear how this impacts results
Low proportion of pts in control group had mRS of 0-2 in 90 day f/u
Broad inclusion with older pts and contraindications to IV alteplase? Poorer prognosis at baseline?
Pts not blinded to intervention
May have influenced their opinions about health/functionality

75. ESCAPE
Included: Patients with proximal intracranial occlusion in the anterior circulation up to 12 hours after symptom onset. Selected based on imaging with ASPECTS score
Excluded: Large infarct core or poor collateral circulation on imaging.
Randomly assigned participants to receive standard care or standard care plus endovascular treatment with use of available thrombectomy devices.
Primary outcome: score on modified Rankin scale at 90 days.
Trial stopped early because of efficacy.
ASPECTS: Alberta Stroke Program Early CT Score – imaging measure of extent of ischemic CVA, 0-10, higher scores indicating smaller infarct core

76. 165 in intervention and 150 in control
Median age 70-71
52% female
NIHSS 16-17
Location of occlusion similar
ASPECTS: Alberta Stroke Program Early CT Score – imaging measure of extent of ischemic CVA, 0-10, higher scores indicating smaller infarct core

77. Stroke onset to randomization 170 minutes
Stroke onset to CT minutes
Stroke onset to start of IV-alteplase minutes
CT to groin puncture 51 minutes
CT to first reperfusion 84 minutes
Stroke onset to first reperfusion 241 minutes
72.7% treated with IV alteplase; 78.7% of the control group

78. Assessment at 90 days 90 day assessment:
A: Overall distribution of scores favored the intervention with larger number of pts having lower mRS
B: In both pts who did and who did not get alteplase, intervention was favored, more significantly in pts not treated with IV alteplase

79. Death – 10.4% in intervention, 19% in control
Large or malignant MCA CVA – 4.8% in intervention, 10.7% in control
Symptomatic ICH – 3.6% in intervention, 2.7% in control
Hematoma at access site – 1.8% in intervention
Perforation of MCA – 0.6% (1 pt) in intervention

80. ESCAPE: Conclusions
Pts with acute ischemic CVA with small infarct core on imaging, proximal intracranial occlusion in the anterior circulation, and moderate to good intracranial collateral circulation, rapid endovascular treatment improved clinical outcome and reduced mortality.
Rapid reperfusion associated with better clinical outcome than slower reperfusion
Shorter interval times in this trial with median time from CT to first reperfusion of 84 minutes
How they did it quickly: parallel decision making and action – groin puncture AND alteplase infusion at the same time
Low rate of general anesthesia (9% in ESCAPE vs 38% in MR CLEAN)

82. EXTEND-IA
Purpose: Prior trials of endovascular therapy for ischemic CVA have produced variable results. Study performed to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes.

83. EXTEND-IA: Methods
Pts with ischemic CVA, occlusion of ICA or MCA, evidence of small ischemic core, who were receiving IV-alteplase <4.5 hrs after onset of ischemic CVA
Assigned to undergo endovascular thrombectomy with the Solitare Flow Restoration stent retriever, or to continue IV-alteplase alone
Primary outcomes: Reperfusion at 24 hrs and early neurological improvement (>8 point reduction on NIHSS or score of 0 or 1 at day 3.
Secondary outcomes included functional score on mRS at 90 days.

84. No significant differences in baseline group
Perfusion-lesion – one with a Tmax delay of more than 6 seconds on CT perfusion imaging

85. Median time from stroke onset to groin puncture 210 minutes
Median time from initial imaging to groin puncture 93 minutes
Median time from initiation of alteplase to groin puncture 74 minutes
Median time from stroke onset to reperfusion or completion of procedure 248 minutes

86. EXTEND-IA: Results
Stopped early due to efficacy after 70 pts had undergone randomization.
Percentage of ischemic territory that underwent reperfusion was higher in endovascular therapy at 24 hrs (median 100% vs 37%) and improved functional outcome at 90 days (71% achieving functional independence vs 40%)
No significant differences in rates of death or symptomatic intracerebral hemorrhage.

87. 100% reperfusion at 24 hrs in endovascular therapy group, 37% in alteplase only group, adjusted odds ratio 4.7
80% with early neurological improvement in endovascular group, 37% in alteplase only group
Reduction of 8+ pts on NIHSS or a score of 1 or 1 at 3 days
mRS – endovascular with median score of 1 and altelpase with median score of 3
Death 9% in endovascular and 20% in alteplase
ICH

88. Results – reperfusion at 24 hrs – in endovascular group, rate of reperfusion at 24 hrs shown
Neurological severity – trend towards improved outcome in endovascular therapy group

89. Scores on mRS at 90 days in intention-to-treat population – Significantly more pts had score of 0, 1, 2 and 3

90. EXTEND-IA: Conclusions
In pts with ischemic CVA and proximal cerebral artery occlusion and salvagable tissue on CT perfusion imaging, early thrombectomy with Solitare FR stent retriever as compared with alteplase alone, improved reperfusion, early neuro recovery and functional outcome.
Limitations: small number of patients limiting subgroup analyses

91. Conclusions
Stroke is a common disorder with significant disability and mortality
Dual antiplatelet therapy for 21 days, with treatment onset within 12 hrs of TIA or minor ischemic stroke, reduces chance of recurrent ischemia without change in bleeding risk
Fluoxetine and potentially other SSRIs may improve motor function in CVA pts at 3 months, potentially through neuromodulation (animal models)
For treatment of symptomatic intracranial stenosis:
Early studies showed aspirin is superior to warfarin
SAMMPRIS trial showed dual antiplatelet therapy for 3 months and aggressive medical treatment was superior to angioplasty and stenting
SAMMPRIS trial also suggested that aggressive medical management alone led to a greater reduction in stroke risk factors than expected and can lower risk of future stroke
Dual antiplatelet therapy 90 days
High intensity statin therapy in pts 75 and younger
Aggressive BP management and LDL management (q30 day assessments)
Aggressive lifestyle modification with significant improvement seen at 4 months
For patients with large artery intracranial occlusion in the anterior circulation, endovascular treatment within 6-12 hrs after stroke symptom onset is superior to alteplase alone without increased risk of hemorrhage or death

92. THANK YOU

93. References
Wang et al. Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. NEJM 2013;369:11-19.
Narushima et al. Current Atheroscl Rep 2002;4:
Chollet et al. Fluoxetine for motor recovery after acute ischaemic stroke. Lancet Neurol 2011;10:
Chomowitz et al. Comparison of Warfarin and Aspirin for Symptomatic Intracranial Arterial Stenosis. NEJM 2005;352:
Chimowitz et al. Stenting vs Aggressive Medical Therapy for Intracranial Arterial Stenosis. NEJM 2011;365:
Derdeyn et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomized trial. Lancet 2014;383:
Amarenco et al. High-Dose Atorvastatin after Stroke or Transient Ischemic Attack. NEJM 2006;355:
Stone et al. Circulation Published online at
Broderick et al. Endovascular therapy after IV t-PA vs t-PA alone for stroke. NEJM 3024;368: )
Saver et al. Solitare Flow Restoration Device vs Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomized, parallel-group, non-inferiority trial. Lancet 2012;380:
Berkhemer et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. NEJM 2015;372:11-20.
Goyal et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. NEJM published online Feb 11, 2015.
Campbell et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. NEJM published online on February 11, 2015.