To review late-window reperfusion trials and analyze the outcomes of thrombolysis and mechanical thrombectomy in imaging-selected ischemic stroke patients.
Approach:
Trial Review: The article reviews late-window trials including DAWN, DEFUSE 3, TRACE-III, and HOPE, focusing on their methodologies and patient populations.
Systems-of-Care Framework: It situates the trials within a systems-of-care framework, distinguishing scenarios where thrombectomy is delayed or unavailable.
Key Findings:
Mechanical thrombectomy (MT) is superior to medical therapy for anterior circulation proximal large-vessel occlusion (LVO) stroke, as shown in late-window trials.
Late-window IVT trials (TRACE-III and HOPE) demonstrate benefits in imaging-selected patients where thrombectomy was not planned or accessible.
Outcomes in late-window IVT trials should not be directly compared to MT trials due to differences in patient populations and baseline prognoses.
Interpretation:
The authors argue that outcomes should be interpreted by comparing each treated arm against its own control group and considering the clinical profiles of enrolled patients.
Limitations:
No randomized, head-to-head late-window trial of IVT versus MT exists.
Differences in baseline prognosis, occlusion site, and imaging selection limit cross-trial comparisons.
Conclusion:
The authors emphasize the need to interpret late-window IVT evidence within each randomized trial rather than through informal comparisons with MT trials.
