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Original research
Endovascular revascularization results in IMS III: intracranial ICA and M1 occlusions
  1. Thomas A Tomsick1,
  2. Sharon D Yeatts2,
  3. David S Liebeskind3,
  4. Janice Carrozzella1,
  5. Lydia Foster2,
  6. Mayank Goyal4,
  7. Ruediger von Kummer5,
  8. Michael D Hill6,
  9. Andrew M Demchuk4,
  10. Tudor Jovin7,
  11. Bernard Yan8,
  12. Osama O Zaidat9,
  13. Wouter Schonewille10,
  14. Stefan Engelter11,
  15. Renee Martin2,
  16. Pooja Khatri12,
  17. Judith Spilker12,
  18. Yuko Y Palesch2,
  19. Joseph P Broderick12
  20. for the IMS III Investigators
  1. 1Department of Radiology, University of Cincinnati Academic Health Center, University Hospital 234 Goodman St, Cincinnati, Ohio, USA
  2. 2Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  3. 3UCLA Stroke Center, 924 Westwood Blvd, Los Angeles, California, USA
  4. 4Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  5. 5Department of Neuroradiology, Dresden University Stroke Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
  6. 6Calgary Stroke Program, Department of Clinical Neurosciences/Medicine/Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Rm 1242A, Foothills Hospital, Calgary, Alberta, Canada
  7. 7The Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  8. 8Division of Neurosciences, Comprehensive Stroke Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia
  9. 9Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin, USA
  10. 10St Antonius Hospital Nieuwegein, Koekoekslaan 1, Nieuwegein 3435 CM 53226, Netherlands
  11. 11University Hospital Basel, Petersgraben 4, Basel, Switzerland
  12. 12Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
  1. Correspondence to Dr Thomas A Tomsick, Department of Radiology, University of Cincinnnati Academic Health Center, UC Health, 234 Goodman St, Cincinnati, OH 45267-0761, USA; thomas.tomsick{at}uchealth.com

Abstract

Background Interventional Management of Stroke III did not show that combining IV recombinant tissue plasminogen activator (rt-PA) with endovascular therapies (EVTs) is better than IV rt-PA alone.

Objective To report efficacy and safety results for EVT of intracranial internal carotid artery (ICA) and middle cerebral artery trunk (M1) occlusion.

Methods Five revascularization methods for persistent occlusions after IV rt-PA treatment were evaluated for prespecified primary and secondary endpoints, after accounting for differences in key baselines variables using propensity scores. Revascularization was scored using the arterial occlusive lesion (AOL) and the modified Thrombolysis in Cerebral Ischemia (mTICI) scores.

Results EVT of 200 subjects with intracranial ICA or M1 occlusion resulted in 81.5% AOL 2–3 recanalization, in addition to 76% mTICI 2–3 and 42.5% mTICI 2b–3 reperfusion. Adverse events included symptomatic intracranial hemorrhage (SICH) (8.0%), vessel perforations (1.5%), and new emboli (14.9%). EVT techniques used were standard microcatheter n=51; EKOS n=14; Merci n=77; Penumbra n=39; Solitaire n=4; multiple n=15. Good clinical outcome was associated with both TICI 2–3 and TICI 2b–3 reperfusion. Neither modified Rankin scale (mRS) 0–2 (28.5%), nor 90-day mortality (28.5%), nor asymptomatic ICH (36.0%) differed among revascularization methods after propensity score adjustment for subjects with intracranial ICA or M1 occlusion.

Conclusions Good clinical outcome was associated with good reperfusion for ICA and M1 occlusion. No significant differences in efficacy or safety among revascularization methods were demonstrated after adjustment. Lack of high-quality reperfusion, adverse events, and prolonged time to treatment contributed to lower-than-expected mRS 0–2 outcomes and study futility compared with IV rt-PA.

Trial registration number NCT00359424.

  • Thrombectomy
  • Thrombolysis
  • Stroke
  • Intervention
  • Device

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