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N Engl J Med. 2013 Mar 7;368(10):914-23. doi: 10.1056/NEJMoa1212793. Epub 2013 Feb 8.

A trial of imaging selection and endovascular treatment for ischemic stroke.

Collaborators (303)

Derdeyn C, Becker K, Hamilton S, Brass L, Sung G, Jahan R, Liebeskind DS, Kidwell CS, Alger JR, Schaewe TJ, Norman J, Russell L, Stidd R, Norato G, Janis S, Moy C, Starkman S, Jahan R, Kidwell CS, Fredieu A, Murayama Y, Ovbiagele B, Saver J, Suzuki S, Vespa P, Villablanca P, Vinuela F, Chute D, Marder V, Rajajee K, Selco S, Vinters H, Kim D, Sanossian N, Liebeskind D, Ali L, Buck B, Tateshima S, Duckwiler G, Restrepo L, Shah S, Towfighi A, Miller C, Ohanian A, Panagotacos J, Gonzalez N, Froehler M, Tenser M, Raychev R, Song S, Kalanithi S, Adamczyk P, Abcede H, Rao N, Yallapragada A, Guzy J, Grunberg I, Kidwell CS, Hsia A, Warach S, Merino J, Burgess R, Liu AH, Bank W, Menon R, Gupta M, Baird A, Fifi J, Benson R, Lynch J, Latour L, Davis L, Forrest AM, Ajani Z, Feng L, Manthena P, Chao K, Vaghasia UG, Kim R, Meyer B, Olson S, Meyer D, Hemmen T, Lyden P, Kerber C, Wong W, Pakbaz S, Al-Khoury L, Cheng Y, Fanale C, Sattin J, Chacon M, Jensen M, Tafreshi G, Brown W, Huisa B, Stemer A, Yip S, Shadeh A, Aleu A, Albright K, Sung SM, Bruce N, Neil W, Sodhi A, Guzik A, Kelly N, Rapp K, Rzesiewicz T, Jurf J, Werner J, Bell J, Schwamm LH, Yoo A, Anderson C, Buonannom F, Fehnel C, Furie K, Gonzalez R, Gurol E, Hirsch J, Hwang D, Kimberly WT, Kummer T, Leslie-Mazwi T, Lev M, Mehta B, Molyneaux B, Ogilvy C, Rabinov J, Rahman C, Reddy V, Rordorf G, Rosand J, Rosenthal E, Rost N, Schaefer P, Silverman S, Viswanathan A, Cloonan L, De Gregorio S, Litalien A, Brouwers H, Caceres J, Pontes Neto OM, Siket M, Thornell B, Amatangelo M, Marshall RS, Meyers PM, Canaan A, Yavagal D, Aziz-Sultan M, Ortiz G, Giannini A, Garza P, Grotta J, Barreto A, Mir O, Parker S, Alderman S, Hess MJ, Kidwell CS, Merino J, Hsia A, Dick B, Olan W, Warach S, Menon R, Burgess R, Gupta M, Baird A, Fifi J, Benson R, Lynch J, Latour L, Forrest AM, Davis L, Kidwell CS, Lee D, McCullough M, Burgess R, Menon R, Landis D, Watson V, Hsieh CR, Russell LC, Norato G, Stidd R, Ramirez G, McCullough-Hicks M, Kowal T, Sutton S, Walker B, Wyllie B, Crandell B, Tomsick TA, Khatri P, Carrozzella JA, Frasure J, Starkman S, Jahan R, Buxton W, Dominick J, Duckwiler G, Kim D, Liebeskind D, Marder V, Porter V, Saver J, Tateshima S, Villablanca P, Vinters H, Vinuela F, Shah S, Towfighi A, Ohanian A, Panagotacos J, Gonzalez N, Froehler M, Tenser M, Raychev R, Song S, Kalanithi S, Adamczyk P, Abcede H, Ali L, Rao N, Yallapragada A, Velani S, Guzy J, Grunberg I, Jovin TG, Wechsler LR, Hammer M, Uchino K, Horowitz M, Gupta R, Vora N, Reddy V, Lin R, Jumaa M, Zaidi S, Jankowitz B, Malik A, Wong C, Spataru O, Nuin XU, DeCesare S, Oakley JI, Adams A, Billigen J, Mallory Y, Santucci TS, Massaro LM, Leifer D, Gobin Y, Salvaggio K, Nikolov B, Adams RJ, Holmstedt C, Jauch EC, Keller G, Parker A, Cruz-Flores S, Vora N, Edgell R, Piriyawat P, Feen E, Mehta S, Kaushal R, Alshekhlee A, Hozemer EM, Fann A, Eller S, Kase CS, Nguyen T, Babikian VL, Romero J, Pikula A, Barest G, Saki O, Lau H, Lyden P, Moser F, Lin F, Raghuram K, Carpenter J, Rai A, Roberts TD, Brooks C, Domico J, Devlin T, Baxter B, Quarfordt S, Talley M, Barton K, Froehler MT, Adams H, Davis P, Hayakawa M, Leira E, Sieren J.

Author information

Department of Neurology and the Stroke Center, Georgetown University, Washington, DC 20007, USA.



Whether brain imaging can identify patients who are most likely to benefit from therapies for acute ischemic stroke and whether endovascular thrombectomy improves clinical outcomes in such patients remains unclear.


In this study, we randomly assigned patients within 8 hours after the onset of large-vessel, anterior-circulation strokes to undergo mechanical embolectomy (Merci Retriever or Penumbra System) or receive standard care. All patients underwent pretreatment computed tomography or magnetic resonance imaging of the brain. Randomization was stratified according to whether the patient had a favorable penumbral pattern (substantial salvageable tissue and small infarct core) or a nonpenumbral pattern (large core or small or absent penumbra). We assessed outcomes using the 90-day modified Rankin scale, ranging from 0 (no symptoms) to 6 (dead).


Among 118 eligible patients, the mean age was 65.5 years, the mean time to enrollment was 5.5 hours, and 58% had a favorable penumbral pattern. Revascularization in the embolectomy group was achieved in 67% of the patients. Ninety-day mortality was 21%, and the rate of symptomatic intracranial hemorrhage was 4%; neither rate differed across groups. Among all patients, mean scores on the modified Rankin scale did not differ between embolectomy and standard care (3.9 vs. 3.9, P=0.99). Embolectomy was not superior to standard care in patients with either a favorable penumbral pattern (mean score, 3.9 vs. 3.4; P=0.23) or a nonpenumbral pattern (mean score, 4.0 vs. 4.4; P=0.32). In the primary analysis of scores on the 90-day modified Rankin scale, there was no interaction between the pretreatment imaging pattern and treatment assignment (P=0.14).


A favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular therapy for acute ischemic stroke, nor was embolectomy shown to be superior to standard care. (Funded by the National Institute of Neurological Disorders and Stroke; MR RESCUE number, NCT00389467.).

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