RCT

DAWN

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct

NEJM, 2018 · Multicenter randomized open-label trial with blinded outcome assessment (n=206)

Clinical question

Does mechanical thrombectomy improve functional independence in patients with acute ischemic stroke presenting 6-24 hours after last known well?

Population: Patients with occlusion of the intracranial internal carotid artery or proximal MCA presenting 6-24 hours with clinical-core mismatch on automated perfusion CT (RAPID)
Intervention: Mechanical thrombectomy with Trevo stent retriever plus standard medical therapy
Comparator: Standard medical therapy alone
Primary outcome: Functional independence (modified Rankin Scale score 0-2) at 90 days
Result: Rate of functional independence at 90 days was 49% in the thrombectomy group vs 13% in the control group (difference 36 percentage points; 95% CI 24 to 47; P<0.001; NNT=2.8). Symptomatic intracranial hemorrhage rates were similar (6% vs 3%, P=0.50).

What the trial found

Mechanical thrombectomy up to 24 hours after last known well in patients with clinical-core mismatch drastically increased functional independence without increasing mortality or intracranial hemorrhage.

Current guideline position

Class I recommendation in AHA/ASA and ESO stroke guidelines.

Clinical interpretation

Expanded the mechanical thrombectomy therapeutic window from 6 hours to 24 hours in imaging-selected large vessel occlusions.

Clinical Context & Relevant Topics (1)

Disease Reference

Acute Ischemic Stroke

Core vs penumbra dynamics, ASPECTS & CT perfusion, Tenecteplase/Alteplase thrombolysis, DAWN/DEFUSE 3 extended thrombectomy, BP targets, and malignant MCA hemicraniectomy.

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