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

Area of Science:

• Neurology
• Interventional Cardiology
• Stroke Medicine

Background:

• Endovascular therapy for large-artery stroke in extended time windows lacks established safety and efficacy data.
• The Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial provides data for subgroup analysis in extended time windows.

Purpose of the Study:

• To evaluate the safety and efficacy of endovascular therapy in patients with large-artery stroke presenting within an extended time window (5.5 to 12 hours).

Main Methods:

• Subgroup analysis of 59 patients from the ESCAPE trial randomized between 5.5 and 12 hours after last seen healthy.
• Assessment of treatment effect sizes for 90-day modified Rankin Scale (mRS) shift, mRS 0-2, mRS 0-1, 24-hour NIHSS scores, and intracerebral hemorrhage.

Main Results:

• No significant treatment heterogeneity was observed between early and extended time windows.
• Endovascular intervention showed a favorable treatment effect across all clinical outcomes in the extended window (19.3% absolute risk difference for mRS 0-2 at 90 days).
• Higher rates of asymptomatic intracerebral hemorrhage occurred in the intervention arm (48.5% vs 11.5%), with no difference in symptomatic hemorrhage.

Conclusions:

• Endovascular treatment may offer benefits for stroke patients presenting within an extended time window.
• Future randomized controlled trials incorporating advanced imaging will be crucial for optimizing patient selection and treatment paradigms for late-presenting stroke.