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Evevident
Original paper
2018NEJMNeurology

DEFUSE 3

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging

RCTStroke thrombectomy

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Overview

In imaging-selected anterior-circulation LVO stroke 6-16 hours from last known well, thrombectomy improved functional outcomes.

Clinical takeaway

DEFUSE 3 reinforced tissue-window selection for late thrombectomy using perfusion/core imaging.

Key result

Functional independence at 90 days was 45% with thrombectomy vs 17% with medical therapy alone.

Practice impact

Advanced imaging can identify late-window thrombectomy candidates.

Evidence

Study design

Randomized, open-label, blinded-endpoint trial.

Enrollment

182

Follow-up

90 days.

Geography

United States

Clinical question

Does perfusion-selected late-window thrombectomy improve outcomes in LVO stroke?

Population

  • Patients with proximal anterior-circulation LVO 6-16 hours from last known well and favorable perfusion imaging (small core, large penumbra).

Intervention

Endovascular thrombectomy plus medical therapy.

Comparator

Medical therapy alone.

Primary outcome

Ordinal shift in mRS at 90 days.

Perfusion-selected thrombectomy 6-16 hours after stroke shifted the disability distribution toward better outcomes and increased functional independence (45% vs 17%).

Common odds ratio / 2.77 / CI 95% CI 1.63-4.70 / p=<0.001

Key results

  • Ordinal mRS shift favored thrombectomy: adjusted common odds ratio 2.77 (95% CI 1.63-4.70; p<0.001).
  • Functional independence (mRS 0-2) at 90 days: 45% with thrombectomy vs 17% with medical therapy.
  • 90-day mortality was lower with thrombectomy (14% vs 26%).
  • The trial was stopped early for efficacy after DAWN reported positive results.

Harms

  • Symptomatic intracranial hemorrhage did not differ significantly (7% thrombectomy vs 4% control).
  • Serious adverse events were similar between groups.

Clinical Use

When to cite

  • When using perfusion imaging to select late-window large-vessel stroke patients for thrombectomy.

Practice impact

  • Advanced imaging can identify late-window thrombectomy candidates.

Applicability

  • Most applicable to patients with proximal anterior-circulation large-vessel occlusion 6-16 hours from last known well and a favorable perfusion-imaging profile.

Limitations

  • Highly selected imaging-positive population using automated perfusion software (RAPID).
  • Results depend on rapid imaging and intervention capability.
  • Stopped early for efficacy, which can overestimate treatment effect.

Common misinterpretations

  • DEFUSE 3 used broader perfusion-based mismatch criteria than DAWN and extended the window to 16 hours, but neither trial supports thrombectomy without demonstrating salvageable tissue.
  • Late-window benefit hinges on imaging selection, not simply time from onset.

Related evidence

DAWN - Similar QuestionMR CLEAN - Earlier Trial

Citation

Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018;378(8):708-718. doi:10.1056/NEJMoa1713973

Endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well plus standard medical therapy resulted in better functional outcomes than standard medical therapy alone among patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion and a region of tissue that was ischemic but not yet infarcted.