International Stroke Conference
February 6–8, 2019

Richard Jackson, MD

I’m writing to you from ISC reporting on an important breakthrough in the hyperacute treatment of ischemic strokes. Dr. Henry Ma reported on a positive study of the EXTEND trial evaluating extending the thrombolytic time window to 9 hours for acute ischemic stroke using perfusion imaging selection.

This was a trial performed in Australia, New Zealand, and Thailand using MRI or CT based perfusion-mismatch with inclusion criteria of  a core <70 mL and a mismatch >10 mL.  The median NIHSS was 11 with a median last known normal (LKN) of 10 hours, median core infarct of 4 mL, and median mismatch of 79 mL.  10% of the of patients had LKN of 4-6 hours, 25% 6-9 hours, and 65% wake up stroke.  72% of the patients had an LVO but did not receive thrombectomy. Despite this, there was a RR 1.44 for MRS 0-1 at 1 month and RR 1.4 for MRS 0-2 at 3 months. There was a RR 2.6 for early improvement in the NIHSS 0-8 points and 51% had 90% recanalization and reperfusion with no difference in death at 90 days. There was a comparable ICH ratio to previous trials with 6% but a RR of 6.9 which did not negate the clinical benefit.

This is a great step towards advanced imaging evaluation of ischemic lesions and reperfusion. One which we have all thought about and been waiting for.