SNIS Lauds ESCAPE and EXTEND-IA Stroke Trials

February 11, 2015—The Society of Neurointerventional Surgery (SNIS) announced that data from the ESCAPE and EXTEND-IA clinical trials studying the treatment of stroke demonstrate that neurointerventional procedures significantly increase the number of patients who are able to live independently without major neurological disabilities. The studies were presented at the American Stroke Association’s International Stroke Conference in Nashville, Tennessee, and were published online ahead of print in The New England Journal of Medicine. Endovascular Today’s coverage of the presentations is available here.

Mayank Goyal, MD, et al published ESCAPE online ahead of print in The New England Journal of Medicine. ESCAPE evaluated endovascular treatment for small-core and anterior circulation proximal occlusion ischemic stroke, with an emphasis on minimizing times from computed tomography to recanalization, and showed that neurointerventional procedures reduce stroke mortality by 50%.

Bruce C.V. Campbell, MD, et al published the EXTEND-IA trial online ahead of print in The New England Journal of Medicine.

SNIS noted that the ESCAPE and EXTEND IA trials are two of three studies (along with SWIFT PRIME) that confirm the findings of the MR CLEAN study. MR CLEAN  showed that the addition of inside-the-artery clot removal is more effective than IV-administered “clot-busting” tissue plasminogen activator (IV-tPA) treatment alone for the treatment of stroke. MR CLEAN was recently published by Olvert A. Berkhemer, MD, et al in The New England Journal of Medicine (2015;372:11–20).

In the society’s press release, SNIS President Peter Rasmussen, MD, commented, “All three of these studies confirm what we are seeing in everyday practice. In many cases, instead of suffering major neurological disability, patients are able to go home to resume their lives. Within-the-artery procedures, which are performed by neurointerventional surgeons, are not the appropriate treatment for every patient suffering from stroke, but for those patients experiencing the most severe types of ischemic strokes, they are life-saving, viable, and effective therapies that offer many benefits over traditional treatments, including shorter recovery times and a better chance to return to normal activities.” Dr. Rasmussen is Director of the Cerebrovascular Center at the Cleveland Clinic in Cleveland, Ohio.

According to SNIS, ESCAPE is the first study to show that the overall stroke mortality rate was reduced by 50% with the endovascular neurointerventional procedure, from two in 10 patients for standard-of-care treatment to one in 10. Both ESCAPE and EXTEND-IA showed better outcomes for those treated with endovascular neurointerventions. In ESCAPE, approximately 30% of patients treated with IV-tPA alone were able to live independently without major neurological disabilities. For patients undergoing neurointerventional treatment, that number increased to 53%. EXTEND-IA showed even better results, with 71% of patients who underwent a neurointerventional procedure returning to independent living compared with 40% in the standard treatment group.

In the SNIS announcement, Peter Mitchell, MD, who served as Coprincipal Investigator of EXTEND-IA, advised that two of the key differences in better outcomes for stroke patients were the use of more advanced brain imaging to select patients most likely to benefit and earlier treatment. Dr. Mitchell is Director of Neurointervention at The Royal Melbourne Hospital, where the EXTEND IA study was conducted. The hospital treats approximately 500 ischemic stroke patients each year and is one of the few stroke centers in the world to treat patients within 20 minutes of arriving in the emergency department, noted SNIS.

Donald Frei, MD, President-Elect of SNIS, added that treatment time is critical. Although ESCAPE showed that endovascular neurointerventions can be performed up to 12 hours from the onset of stroke, the success of the trial can be credited to fast treatment and the use of brain and blood vessel imaging. In ESCAPE, investigators were on average 2 hours faster in opening the blocked blood vessels than in previously reported trials.

Dr. Frei stated in the SNIS announcement, “These positive studies are important milestones in the transformation of care for stroke patients, but it’s also important to understand that the comprehensive stroke centers that participated excel in providing this type of care. The results may not be replicable in every hospital. It’s important that when stroke occurs, the disease is identified quickly and patients are transported to facilities that are equipped to provide the best evidence-based interventions for ischemic and hemorrhagic stroke management.”