incomplete Journal Club Article
. "Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands". The New England Journal of Medicine. 2015. 372(1):11-20.

Clinical Question

Does endovascular intervention improve functional outcomes in patients with acute ischemic stroke secondary to large vessel occlusion in the anterior circulation?


Intraarterial treatment in select patients with AIS 2/2 proximal large vessel occlusion provides improved functional outcomes at 90 days.

Major Points

  • 3 prior trials published in 2013 (IMS III, Synthesis EXP, MR RESCUE) showed no benefit of mechanical thrombectomy over tPA alone in AIS
  • Improved functional outcomes at 90 days using MT +/- tPA in select patients with acute ischemic stroke
  • No difference in mortality
  • Proved safety with similar rates of symptomatic ICH
  • Completion of this trial lead to interim analysis of similar trials and consequent closure (ESCAPE, EXTEND-1A, SWIFT PRIME, REVASCAT)

Study Design

  • Prospective, Randomized multicenter trial
  • tPA vs tPA + IAT in patients with AIS within 6 hours with LVO
  • 16 hospitals in the Netherlands
  • N=500
  • 267 control cohort
  • 233 interventional cohort


  • adults in the Netherlands
  • Median age 65
  • Median NIHSS 17 in interventional cohort, 18 in control

Patient Demographics

  • Adults with acute ischemic stroke presenting under 6 hours in the Netherlands

Inclusion Criteria

  • 18 years or older
  • Acute ischemic stroke presenting within 6 hours of onset
  • NIHSS 2+
  • confirmed large vessel occlusion - ICA, M1 or M2

Exclusion Criteria

  • Infarction in territory of occluded artery in past 6 weeks
  • Plts <40k, INR >3, aPTT > 50


  • Intraarterial treatment
  • Arterial catheterization with IA thrombolysis or mechanical thrombectomy or both


  • Improved functional outcomes at 90 days in interventional group
  • no significant difference in mortality
  • no significant difference in occurrence of symptomatic intracranial hemorrhage

Primary Outcome

  • Independent functional outcome at 90 days measured by modified Rankin Score system
  • Absolute difference of 13.5 % between rates of functional independence (mRS 0-2)
  • mRS (0-2) 32.6% intervention group
  • mRS (0-2) 19.1% in control

Secondary Outcomes

  • NIHSS at 24 hours, 5-7 days or at discharge
  • Arterial recanalization at 24 hours by CTA/MRA
  • Infarct size by CT at 5-7 days

Subgroup analysis

Criticisms & Further Discussion

External Links

See Also