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Clinical Question

Perfusion imaging or non-contrast CT for late-window selection?

Synthesises 8 trialsevolution from CT-perfusion / MRI mismatch (DAWN, DEFUSE-3) to plain-CT and MRI ASPECTS selection (RESCUE-Japan LIMIT, LASTE, SELECT2, ANGEL-ASPECT)

What does the guideline say? (2 sections)

  • Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke (EXTEND)· 2019

    Among the patients in this trial who had ischemic stroke and salvageable brain tissue, the use of alteplase between 4.5 and 9.0 hours after stroke onset or at the time the patient awoke (if within 9 hours after the midpoint of sleep) resulted in a higher percentage of patients with no or minor neurologic deficits than the use of placebo. There were more cases of symptomatic cerebral hemorrhage in the alteplase group than in the placebo group.

    Source: Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke (EXTEND)

  • MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset (WAKE-UP)· 2018

    In patients with acute stroke with an unknown time of onset, intravenous alteplase guided by a mismatch between diffusion-weighted imaging and FLAIR in the region of ischemia resulted in a significantly better functional outcome and numerically more intracranial hemorrhages than placebo at 90 days.

    Source: MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset (WAKE-UP)

The trials cited in the guideline's supportive text appear below.

Trials in this question· 8

DAWN2018
Thrombectomy to 24 h with clinical–core mismatch: 49% vs 13% independence, NNT 2.8.
+36 / 100NNT 2.8
DEFUSE-32018
Perfusion-selected thrombectomy at 6–16 h triples functional independence (45% vs 17%).
+28 / 100NNT 3.6
EXTEND2019
Alteplase 4.5–9 h with perfusion-selected imaging improves recovery.
+6 / 100NNT 17
RESCUE-Japan LIMIT2022
EVT for ASPECTS 3-5 LVO improves 90-day mRS 0-3 (31% vs 13%).
NNT 5RR 2.43 (1.35-4.37)
LASTE2024
Large-core EVT (ASPECTS ≤5) shifted median mRS from 6 to 4 and cut mortality 55%→36%.
NNT 4 (mRS shift)gOR 1.63 (1.29–2.06)
TENSION2023
Large-core EVT (ASPECTS 3–5) by NCCT shifted median mRS 5→4; mortality 51%→40%.
SuperiorcOR 2.58 (1.60–4.15)
SELECT-22023
EVT for anterior LVO with large ischemic core (ASPECTS 3–5 or core ≥50 mL) within 24 h shifts mRS toward less disability.
+13 pp mRS 0–2gOR 1.51
ANGEL-ASPECT2023
EVT improves ordinal mRS shift in broader large-core anterior LVO (ASPECTS 3–5 or core 70–100 mL).
gOR 1.37gOR 1.37 (P=0.004)

Related questions

Does my LVO patient need EVT?

early window, late window, large-core, and MeVO boundary

Should I do EVT for large-core stroke (low ASPECTS)?

five positive RCTs (2022–2024) reversing the small-core-only EVT paradigm

When can I give tPA?

0–3 h classic window through imaging-selected extended window

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