NINDS
1995Question
Does IV alteplase given within 3 hours of ischemic stroke onset improve outcomes?
Bottom line
Yes — absolute increase in favorable outcomes despite a higher symptomatic ICH rate. Established IV thrombolysis as standard of care.
The Library
Landmark stroke trials.
A growing reference of the trials that shaped how stroke is treated — one paragraph each, organized by the question they answered. Deeper articles link out where they exist.
Educational summaries — consult primary sources for clinical decisions.
§ 01 · Thrombolysis
Acute IV reperfusion.
ECASS III
2008Question
Does IV alteplase work in the 3 to 4.5 hour window?
Bottom line
Yes — modestly improved outcomes. Extended the treatment window to 4.5 hours.
§ 02 · Thrombectomy
Endovascular therapy.
MR CLEAN
2015Question
Does mechanical thrombectomy plus standard care beat standard care alone in anterior-circulation LVO?
Bottom line
Yes — dramatically. First positive modern thrombectomy trial. Opened the era of EVT.
ESCAPE
2015Question
EVT with rapid workflow and CT-angiography-based selection out to 12 hours.
Bottom line
Substantial benefit. Reinforced the role of imaging-guided selection and fast workflow.
SWIFT PRIME
2015Question
Solitaire stent retriever in anterior LVO within 6 hours.
Bottom line
Significant functional benefit. Confirmed stent-retriever EVT in the early window.
EXTEND-IA
2015Question
EVT with CT-perfusion-based selection (small core, large penumbra) within 6 hours.
Bottom line
Strongly positive. Established the value of perfusion imaging to identify salvageable tissue.
HERMES
2016Question
Pooled individual-patient meta-analysis of the five 2015 EVT trials.
Bottom line
NNT roughly 2.6 for 1-point mRS improvement. Cemented EVT as one of the most effective treatments in medicine.
§ 03 · Late window
Extending the clock.
DAWN
2018Question
EVT in the 6 to 24 hour window using clinical-core mismatch.
Bottom line
Profoundly positive. NNT roughly 2 for functional independence. Opened the late window.
DEFUSE 3
2018Question
EVT in the 6 to 16 hour window using perfusion-imaging mismatch.
Bottom line
Strongly positive. Confirmed the perfusion-imaging selection approach in the late window.
§ 04 · Large core
Beyond the small core.
RESCUE-Japan LIMIT
2022Question
EVT for large-core ischemic stroke (ASPECTS 3-5).
Bottom line
Better outcomes with EVT despite a higher ICH rate. First positive large-core trial.
SELECT2
2023Question
EVT for large-core anterior LVO (ASPECTS 3-5 or core ≥ 50 mL).
Bottom line
Significant benefit with EVT. Helped extend EVT eligibility into larger cores.
ANGEL-ASPECT
2023Question
EVT in large-core anterior LVO (ASPECTS 3-5) within 24 hours.
Bottom line
Positive. Reinforced EVT benefit in selected large-core strokes.
TENSION
2023Question
EVT vs medical management in large-core anterior LVO (ASPECTS 3-5).
Bottom line
Stopped early for benefit. Consistent with SELECT2 and ANGEL-ASPECT.
§ 05 · Anticoagulation
When to start AC after AFib stroke.
ELAN
2023Question
Early vs late initiation of DOAC after ischemic stroke with atrial fibrillation.
Bottom line
Early DOAC was non-inferior — numerically favored — for the composite of recurrent stroke and bleeding. Supports earlier anticoagulation in selected patients.
OPTIMAS
2024Question
Early (≤ 4 days) vs delayed DOAC after ischemic stroke with AFib.
Bottom line
Early was non-inferior. Together with ELAN, supports shifting toward earlier DOAC initiation in most patients.
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