Endovascular Therapy for Acute Stroke with a Large Ischemic Region (RESCUE-Japan LIMIT Trial)

• Prior RCTs have established the efficacy of endovascular therapy (EVT) for large vessel occlusions with small or medium-sized completed stroke (“core” volume <70 mL). But for patients who present with a large, completed infarct, the risk of reperfusion hemorrhage and lack of salvageable function has been thought to reduce the benefit of emergent thrombectomy.

• A meta-analysis of observational studies suggested that EVT for patients with ASPECT (CT-based evaluation of MCA infarct) score of 3-5 may lead to better functional outcomes than medical care alone

• This multicenter, open-label, randomized trial conducted in Japan

• 203 patients randomized to EVT (101) or medical management (102). All patients had ASPECTS of 3-5 measured on MRI, indicating a large core infarct

• Primary outcome of mRS 0-3 at 90 days was achieved in 31.0% in the EVT group, compared with 12.7% in the medical group (RR 2.43, p=0.002)

• Secondary outcomes included mRS shift towards better outcome at 90 days favoring EVT, and improvement of >8 points on NIHSS, which was seen in 31% of the EVT group and 8.8% of the medical group (RR 3.51)

• ICH was more common in the EVT group (58.0% vs 31.4%, p<0.001); symptomatic ICH was no different between groups (9 vs 5%)

• There are some unique aspects of this trial related to its country of origin (Japan) and the local protocols for stroke treatment:
  • ASPECT scoring of the infarct size was based on MRI in this study, rather than CT with CT perfusion; CT is probably more widely used and may be more accurate
  • Alteplase was used in only 27% of cases in each group and at a lower dose than typically used in many other countries; higher dose/utilization may have led to lower initial NIHSS and perhaps excluded some patients from the trial
  • The timing of stroke onset was <6h (or 6-24h if the imaging indicated the stroke ictus was <6h from presentation); so these results may not be generalizable to late presenting strokes with large core

• A question to ponder: Are we trading death for functional disability in some of these cases? mRS of 0-1 at 90 days was only achieved in 14% of patients with EVT, and mRS of 0-1 was only achieved in 5%

Source

Source: New England Journal of Medicine