Stroke: ESCAPE Results Show Dramatic Benefit

Quickly removing clots inside the arteries of patients who have suffered ischemic strokes works far better than simply trying to dissolve the obstructions with drugs like tissue plasminogen activator (tPA) a 22-center study of 316 such patients found. The trial was called ESCAPE, which stands for Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times.

ESCAPE is one of several trials that have essentially confirmed the findings of the 2014 Dutch study known as MR CLEAN.

The effectiveness of these neurointerventional treatments had been considered unproven, but the new evidence shows that this endovascular therapy works well. It dramatically alters the prognoses for many such patients, said Michael Hill, MD, MSc, of the University of Calgary in Alberta, Canada. With colleagues Hill presented his findings today at the American Heart Association/American Stroke Association International Stroke Conference in Nashville, Tenn.

In the international ESCAPE study, all patients had CT scans to confirm their diagnosis of stroke and -- where appropriate -- got clot-dissolving therap with tPA. About 25% of patients could not have the drug for a variety of reasons, such as already taking other anticoagulants. About half of the patients in the trial (including those who couldn't take the tPA) also got the interventional treatment, given within 90 minutes of that CT.

Hill said age was not a barrier to inclusion in the trial "We took them in in their 80s and 90s," he said, as long as the patients had been indenpendent and othersie healthy before the stroke.

The doctors also only offered the intervention whose strokes were confirmed by CTs that also showed blood was flowing around the blockage, keeping the brain tissue alive.

With tPA alone, about 30 % of patients survived without major disability. But with those who had the neurointerventional treatment, that rate went up to 53%.

“The bottom line is this is a totally cool study,” Hill said in an interview last night, “this will change the care of patients around the world—it already has.”

The researchers, whose work is being published today in the New England Journal of Medicine, found the interventional treatment, combined with standard clot-dissolving therapy, achieved a 50% reduction in mortality of these stroke patients, Hill said.

These were patients with large vessel blockage, who often die within 90 days of the event, or become so disabled that they need long-term nursing home care.

“Stroke is a devastating illness,” Hill said, one that is also expensive to take care of, since patients require both medical attention and help with activities of daily living.

The therapy resulted in recanalization rates of about 80%.It was halted early an interim analysis revealed that the study had crossed a pre-planned overwhelming efficacy boundary. Follow-up continues on the remaining 72 patients in the trial.

Donald Frei MD, neurointerventional principal investigator for the ESCAPE trial site at the Colorado Neurological Institute in Denver, Colorado agreed.

Another trial participant,

"These landmark results show beyond any doubt that we can help millions of people worldwide get back to independence from a devastating emergent large vessel occlusion with inside the artery treatment, Frei said. While it is hard to predict when those benefits could become standard practice, he added, "I know I will be treating many more patients [using the intervention] starting right now!"

Frei is president-elect of the Society for Neurointerventional Surgery.

The overall conclusion, as stated in the study abstract, is that with careful patient selection with CT, very fast treatment, and by using modern devices to achieve high reperfusion, there is “an overwhelming clinical benefit” to clot removal plus standard treatment.

Or, as Hill put it in the interview, “This is great for patients—it is terrific that they can helped.”

The study was partly funded by Covidien.