ESCAPE Trial: Rapid EVT for Small-Core LVO With Good Collaterals
In patients with disabling anterior circulation LVO, small infarct cores, and good collaterals on multiphase CTA, does rapid endovascular thrombectomy added to standard care within 12 hours improve functional outcome at 90 days compared with standard care alone?
Goyal et al. (NEJM 2015) · doi:10.1056/NEJMoa1414905 · 316 patients
Population
Included
- Age 18 years or older with disabling acute ischemic stroke
- NIHSS greater than 5
- Pre-stroke functional independence (Barthel index 90 or higher)
- Small infarct core on noncontrast CT (ASPECTS 6 to 10)
- Moderate to good collateral circulation on multiphase CTA (filling of 50% or more of pial arterial circulation in the affected MCA territory)
- Proximal anterior circulation occlusion (intracranial ICA or M1 MCA, including M1-equivalent)
- Treatment achievable within 12 hours of symptom onset
Clinical (heterogeneous sampling frame)
- Acute ischemic stroke
- Age 18 or greater
- Onset (last-seen-well) time to randomization time <12 hours
- Disabling stroke defined as a baseline NIHSS >5 at the time of randomization
- Pre-stroke (24 hours prior to stroke onset) independent functional status in activities of daily living with modified Barthel Index >90. Patient must be living in their own home, apartment or seniors lodge where no nursing care is required
Imaging (homogeneous target population)
- Confirmed symptomatic intracranial occlusion, based on single phase, multiphase or dynamic CTA, at one or more of the following locations: Carotid T/L, M1 MCA, or M1-MCA equivalent (2 or more M2-MCAs). Anterior temporal artery is not considered an M2
- Non-contrast CT and CTA for trial eligibility performed or repeated at ESCAPE stroke center with endovascular suite on-site
- Endovascular treatment intended to be initiated (groin puncture) within 60 minutes of baseline non-contrast CT with target baseline non-contrast CT to first recanalization of 90 minutes
- Signed informed consent or appropriate signed deferral of consent where approved
Excluded
- Large established infarct core (ASPECTS less than 6)
- Poor collateral circulation on multiphase CTA
- Posterior circulation stroke
- Severe pre-stroke disability
- Standard contraindications to endovascular therapy
- Baseline non-contrast CT reveals a moderate/large core defined as extensive early ischemic changes of ASPECTS 0-5 in the territory of symptomatic intracranial occlusion
- Other confirmation of a moderate to large core defined one of three ways: (a) on single phase, multiphase or dynamic CTA: no or minimal collaterals in a region greater than 50% of the MCA territory when compared to pial filling on the contralateral side (multiphase/dynamic CTA preferred); OR (b) on CT perfusion (>8 cm coverage): a low CBV and very low CBF ASPECTS <6 AND in the symptomatic MCA territory; OR (c) on CT perfusion (<8 cm coverage): a region of low CBV and very low CBF >1/3 of the CTP imaged symptomatic MCA territory
- Groin puncture is not possible within 60 minutes of the first slice of non-contrast CT acquisition (if CTP is performed it should be done after CTA)
- No femoral pulses or very difficult endovascular access that will result in a non-contrast CT-to-recanalization time longer than 90 minutes, or an inability to deliver endovascular therapy
- Pregnancy; if a woman is of child-bearing potential a urine or serum beta HCG test is positive
- Severe contrast allergy or absolute contraindication to iodinated contrast
- Suspected intracranial dissection as a cause of stroke
- Clinical history, past imaging or clinical judgment suggests that the intracranial occlusion is chronic
- Patient has a severe or fatal comorbid illness that will prevent improvement or follow-up or that will render the procedure unlikely to benefit the patient
Source: ClinicalTrials.gov NCT01778335· Retrieved 2026-06-08
Primary Outcome — mRS Distribution at 90 Days
All randomized patients (small core, good collaterals)
Study Arms
- Agent
- Mechanical thrombectomy with available thrombectomy devices. Retrievable (stent) retrievers were recommended; suction through a balloon guide catheter in the relevant ICA during thrombus retrieval was also recommended.
- Route
- Endovascular
- Frequency
- Single procedure preceded by cerebral angiogram. Workflow targets: study NCCT-to-groin-puncture ≤60 min; study NCCT-to-first-reperfusion (first reflow in the MCA) ≤90 min.
- Duration
- One-time procedure
- Co-interventions
- Guideline-based medical care, including IV alteplase within 4.5 h of onset if local guideline criteria were met (given in BOTH arms). General anesthesia was discouraged.
Technique + workflow targets from Goyal NEJM 2015 p.1021 (Treatments / Participants). In practice: retrievable stents used in 130/151 (86.1%) procedures; of those, 100 (77.0%) Solitaire (Covidien); GA in 9.1%. Device-agnostic; no single brand mandated.
- Agent
- Current standard of care per Canadian or local acute-stroke management guidelines (no protocol-mandated thrombectomy)
- Route
- Medical
- Co-interventions
- Guideline-based medical care, including IV alteplase within 4.5 h of onset if local guideline criteria were met (given in BOTH arms)
Control = current standard of care per Canadian/local acute-stroke guidelines (Goyal NEJM 2015 p.1021). Granular control-arm medical management (BP, glucose, antithrombotic) is in the Supplementary Appendix (see appendix-gap flag). IV alteplase actually given: control 78.7%, intervention 72.7% (Table 1). 18/150 control patients crossed over to EVT.
Trial Design
Type
- International randomized trial
- Standard care vs standard care plus EVT
- CT/CTA selection for small core and moderate-good collaterals
- Treatment allowed up to 12 hours from onset
Timeline
Stopped early for efficacy
N
316
Enrollment
International phase 3 RCT enrolling 316 patients across 22 centers between February 2013 and October 2014 (Goyal NEJM 2015). Stopped early for efficacy.
ClinicalTrials.gov
NCT01778335Bedside Pearl
For an LVO patient up to 12 hours from onset with ASPECTS of 6 or higher and good collaterals on multiphase CTA, ESCAPE supports thrombectomy with a striking absolute mortality reduction of about 9 percentage points. Aim to keep the CT-to-puncture interval as short as the trial achieved.
See also