Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial

J W Evans¹, B R Graham¹, P Pordeli², F S Al-Ajlan¹, R Willinsky³, W J Montanera³, J L Rempel⁴, A Shuaib⁵, P Brennan⁶, D Williams⁷, D Roy⁸, A Y Poppe⁹, T G Jovin¹⁰, T Devlin¹¹, B W Baxter¹², T Krings¹³, F L Silver¹⁴, D F Frei¹⁵, C Fanale¹⁴, D Tampieri¹⁵, J Teitelbaum¹⁶, D Iancu¹⁷, J Shankar¹⁸, P A Barber^{1

19}, A M Demchuk^{1

19}, M Goyal^{1

19}, M D Hill^{1

2

19}, B K Menon^{20

2

19

21}; ESCAPE Trial Investigators

Affiliations

¹ From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).
² Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
³ Department of Medical Imaging (R.W., W.J.M.).
⁴ Departments of Radiology (J.L.R.).
⁵ Medicine (Neurology) (A.S.), University of Alberta, Edmonton, Alberta, Canada.
⁶ Departments of Neuroradiology (P.B.).
⁷ Geriatric and Stroke Medicine (D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland.
⁸ Departments of Radiology (D.R.).
⁹ Neurosciences (A.Y.P.), Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada.
¹⁰ Department of Neurology (T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
¹¹ Erlanger Medical Centre (T.D.).
¹² Department of Radiology (B.W.B), Erlanger Hospital, University of Tennessee, Chattanooga, Tennessee.
¹³ Division of Radiology (T.K.).
¹⁴ Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada.
¹⁵ Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado.
¹⁶ Montreal Neurological Institute (J.T.), McGill University, Montreal, Quebec, Canada.
¹⁷ Department of Radiology (D.I.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
¹⁸ Department of Neuroradiology (J.S.), Dalhousie University, Halifax, Nova Scotia, Canada.
¹⁹ Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada.
²⁰ From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.) docbijoymenon@gmail.com.
²¹ Foothills Medical Centre (B.K.M.), Calgary, Alberta, Canada.

PMID: 29191873
PMCID: PMC7410688
DOI: 10.3174/ajnr.A5462

Randomized Controlled Trial

Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial

J W Evans et al. AJNR Am J Neuroradiol. 2018 Jan.

. 2018 Jan;39(1):102-106.

doi: 10.3174/ajnr.A5462. Epub 2017 Nov 30.

Authors

Affiliations

¹ From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.).
² Community Health Sciences and Department of Medicine (P.P., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
³ Department of Medical Imaging (R.W., W.J.M.).
⁴ Departments of Radiology (J.L.R.).
⁵ Medicine (Neurology) (A.S.), University of Alberta, Edmonton, Alberta, Canada.
⁶ Departments of Neuroradiology (P.B.).
⁷ Geriatric and Stroke Medicine (D.W.), Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland.
⁸ Departments of Radiology (D.R.).
⁹ Neurosciences (A.Y.P.), Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada.
¹⁰ Department of Neurology (T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
¹¹ Erlanger Medical Centre (T.D.).
¹² Department of Radiology (B.W.B), Erlanger Hospital, University of Tennessee, Chattanooga, Tennessee.
¹³ Division of Radiology (T.K.).
¹⁴ Division of Neurology (F.L.S., C.F.), Department of Medicine, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada.
¹⁵ Colorado Neurological Institute (D.F.F., D.T.), Engelwood, Colorado.
¹⁶ Montreal Neurological Institute (J.T.), McGill University, Montreal, Quebec, Canada.
¹⁷ Department of Radiology (D.I.), The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
¹⁸ Department of Neuroradiology (J.S.), Dalhousie University, Halifax, Nova Scotia, Canada.
¹⁹ Hotchkiss Brain Institute (P.A.B., A.M.D., M.G., M.D.H., B.K.M.), University of Calgary, Calgary, Alberta, Canada.
²⁰ From the Departments of Clinical Neurosciences and Radiology (J.W.E., B.R.G., F.S.A.-A., P.A.B., A.M.D., M.G., M.D.H., B.K.M.) docbijoymenon@gmail.com.
²¹ Foothills Medical Centre (B.K.M.), Calgary, Alberta, Canada.

PMID: 29191873
PMCID: PMC7410688
DOI: 10.3174/ajnr.A5462

Abstract

Background and purpose: The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial.

Materials and methods: Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses.

Results: There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage.

Conclusions: Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.

Trial registration: ClinicalTrials.gov NCT01778335.

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References

1. Powers WJ, Derdeyn CP, Biller J, et al. ; American Heart Association Stroke Council. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2015;46:3020–35 10.1161/STR.0000000000000074 - DOI - PubMed
1. Casaubon LK, Boulanger JM, Glasser E, et al. ; Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations: Acute Inpatient Stroke Care Guidelines, update 2015. Int J Stroke 2016;11:239–52 10.1177/1747493015622461 - DOI - PubMed
1. Goyal M, Menon BK, van Zwam WH, et al. ; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723–31 10.1016/S0140-6736(16)00163-X - DOI - PubMed
1. Saver JL, Goyal M, van der Lugt A, et al. ; HERMES collaborators. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 2016;316:1279–88 10.1001/jama.2016.13647 - DOI - PubMed
1. Jovin TG, Nogueira RG. Dawn in full daylight. In: Proceedings of the 3rd European Stroke Organisation Conference, Prague, Czech Republic; May 16–18, 2017

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Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial

Affiliations

Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial

Authors

Affiliations

Abstract

Figures

References

Publication types

MeSH terms

Associated data

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical