Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window (Tension)

Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window: a Randomized, Controlled Trial

TENSION (Efficacy and safety of ThrombEctomy iN Stroke with extended leSION and extended time window) is a prospective, open label, blinded endpoint (PROBE), European two-arm, randomized, controlled, post-market study to compare the safety and effectiveness of endovascular thrombectomy as compared to best medical care alone in the treatment of acute ischemic stroke patients with extended stroke lesions defined by an Alberta Stroke Program Early CT Score (ASPECTS) score of 3-5 and in an extended time window (up to 12 hours or unknown time of symptom onset). Up to 665 subjects will be randomized. Primary endpoint will be functional outcome assessed by the modified Rankin scale at 90 days post-stroke ("mRS shift analysis"). By this, TENSION will provide evidence of efficacy and safety of thrombectomy in an acute stroke population with uncertain benefit of endovascular stroke treatment.

Study Overview

• Status: Terminated
• Conditions: Stroke, Acute; Cerebral Stroke; Cerebrovascular Stroke; Apoplexy; Brain
• Intervention / Treatment: Device: Thrombectomy; Other: Best medical care

Detailed Description

This study is a prospective, open label, blinded endpoint (PROBE),European, two-arm, randomized, controlled, post-market study to compare the safety and effectiveness of endovascular thrombectomy as compared to best medical care alone in the treatment of acute ischemic stroke (AIS) in patients with extended stroke lesions defined by an ASPECT score of 3-5 and in an extended time window (up to 12 hours, or unknown time of symptom onset). This is an adaptive design study, with prospectively stated interim analyses with specified stopping rules allowing for the possibility early termination based on either a determination of study success or futility.

Up to 665 subjects will be enrolled in the study and randomized for the Intention to treat analysis set. The randomization will be stratified by time from symptom onset (0-6h and 6-11h/wake up stroke), and stroke severity (NIHSS ≤18, NIHSS >18).

Interim data analysis is planned after the primary endpoint has been obtained for one third and two thirds of the patients. At each of these sample sizes, the available 90-day mRS data for each treatment arm will be evaluated. Safety interim analysis will be performed after one third and two thirds of the patients have been included.

Subjects who meet the inclusion criteria will be randomized in a 1:1 ratio to one of the following two treatment arms:

Arm 1: best medical care Arm 2: endovascular thrombectomy and best medical care The primary objective of this study is to test efficacy and safety of thrombectomy in acute stroke patients with uncertain benefit of endovascular stroke treatment, i.e. extended ischemic lesion size with an ASPECT score of 3-5 or late (up to 12 hours) or unknown time window as compared to best medical care alone.

Approximately 40 sites in Up to 20 sites in 8-10 European countries Patients presenting with acute ischemic stroke (AIS) based on focal occlusion in the M1 segment of the middle cerebral artery (MCA), and/or the intracranial segment of the distal internal carotid artery (ICA), determined by Magnetic Resonance Angiography (MRA) or Computed Tomographic Angiography (CTA), and who meet all eligibility criteria will be considered for study enrollment.

• Study Type: Interventional
• Enrollment (Actual): 253
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Austria
  • Graz, Austria, 8036
    • Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University Graz
  • Innsbruck, Austria, 6020
    • Medical University Innsbruck
  • Linz, Austria, 4020
    • Neuroradiology, Keppler University Hospital Linz
  • Salzburg, Austria, 5020
    • Department of Neurology, Reseach Institute of Neurointervention, Christian Doppler Clinic, Paracelsus Medical University Salzburg
• Canada
  • Alberta
    • Calgary, Alberta, Canada, T2N 1N4
      • University of Calgary
• Czechia
  • Brno, Czechia, 65691
    • St. Anne's University Hospital Brno
  • Hradec Kralove,, Czechia, 50005
    • Faculty Hospital Hradec Králové
  • Ostrava, Czechia, 70852
    • Comprehensive stroke center,University Hospital Ostrava
  • Prague, Czechia, 150 30
    • Homolka Hospital Prague
  • Usti nad Labem, Czechia, 40003
    • Dept. of Radiology, Masaryk hospital
• Denmark
  • Aalborg, Denmark, 9000
    • Aalborg University Hospital
  • Aarhus, Denmark, 8000
    • Aarhus University Hospital
  • Copenhagen, Denmark, 2100
    • University Hospital Rigshospitalet
• France
  • Clermont-Ferrand, France, 63000
    • CHU Gabriel Montpied, Clermont-Ferrand
  • Le Kremlin-Bicêtre, France, 94270
    • Hôpiteaux Universitaires Paris-Sud, Hôpital Bicêtre
  • Paris, France, 75013
    • Hôpital Pitié-Salpêtrière
  • Reims, France, 51100
    • Université Reims Champagne Ardenne/ Department of Neuroradiology, Hôpital Maison Blanche
  • Rennes, France, 35033
    • CHU de Rennes/Centre Urgences-Réanimations
  • Tours, France, 37044
    • CHRU Hôpiteaux de Tours / Hôpital Bretonneau
• Germany
  • Bochum, Germany, 44892
    • Universitätsklinikum KK Bochum-Langendreer Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie und Nuklearmedizin
  • Bonn, Germany, 53127
    • Universitatsklinikum Bonn
  • Bremen, Germany, 28211
    • Gesundheit Nord gGmbH Klinikverbund Bremen
  • Dortmund, Germany, 44137
    • Klinik für Radiologie und Neuroradiologie am Klinikum Mitte
  • Dresden, Germany, 01307
    • Universitatsklinikum Carl Gustav Carus Dresden
  • Essen, Germany, 45131
    • Alfried Krupp Krankenhaus Rüttenscheid
  • Flensburg, Germany, 24939
    • Diakonissenkrankenhaus Flensburg
  • Hamburg, Germany, 20251
    • Universitatsklinikum Hamburg-Eppendorf
  • Heidelberg, Germany, 69120
    • Neuroradiologie Universitätsklinikum Heidelberg
  • Leipzig, Germany, 04103
    • Universitätsklinikum Leipzig AöR
  • Lübeck, Germany, 23538
    • UKSH Universitätsklinikum Schleswig-Holstein Campus Lübeck
  • München, Germany, 81377
    • Klinikum der Universität München
  • München, Germany, 81675
    • Technische Universität München / Klinikum rechts der Isar
  • Würzburg, Germany, 97080
    • Universitatsklinikum Wurzburg
  • Nordrhein-Westfalen
    • Minden, Nordrhein-Westfalen, Germany, 32429
      • Universitätsinstitut für Diagnostische Radiologie, Neuroradiologie und Nuklearmedizin Johannes Wesling Klinikum Minden
  • Sachsen-Anhalt
    • Magdeburg, Sachsen-Anhalt, Germany, 39120
      • Otto-von-Guericke-university Magdeburg
• Norway
  • Bergen, Norway, 5021
    • Haukeland University Hospital
  • Oslo, Norway, NO-0407
    • Oslo University Hospital
  • Tromsø, Norway, 9038
    • The Arctic University of Norway
• Slovakia
  • Martin, Slovakia, 03659
    • Comenius University's Jessenius Faculty of Medicine and University Hospital
  • Trnava, Slovakia, 91775
    • Faculty Hospital Trnava
• Spain
  • Madrid, Spain, 28046
    • La Paz University Hospital
• Switzerland
  • Basel, Switzerland, CH-4031
    • University Hospital Basel

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Randomization within 11 hours after stroke onset (if known) or last seen well.
• Endovascular treatment is expected to be finished within 12 hours after known symptom onset or last seen well by judgment of the interventional neuroradiologist in charge (if stroke onset is known).
• Patient must demonstrate clinical signs and symptoms attributable to target area of occlusion consistent with the diagnosis of ischemic stroke, including impairment of the following: language, motor function, sensation, cognition, gaze, and/or vision for at least 30 minutes without relevant improvement.
• Female and male patient above 18 years of age
• NIHSS Score of <26
• Signed informed consent (IC) form by patient or legal guardian, or inclusion of patient's presumptive will by investigator under emergency situation, but after consultation of an independent physician who is familiar with these types of illness if the other options are not possible according to local approval.
• Prior to new focal neurological deficit, mRS score was ≤2.

Imaging Inclusion Criteria

• A new focal occlusion confirmed by imaging (MRA/CTA) to be accessible to the thrombectomy device, and located in the M1 of the middle cerebral artery (MCA) and/or the intracranial segment of the distal internal carotid artery (ICA).
• CT (non-contrast CT) or DWI with an ASPECT score of 3-5

Clinical exclusion criteria

• Patient is an active participant in another drug or device treatment trial for any disease state or patient is expected to start participation in another drug or device treatment trial while enrolled in this protocol, unless approved by Sponsor.
• Patient has pre-existing neurological or psychiatric disease that could impede the study results or would confound the neurological or functional evaluations.
• Patient has vascular disease preventing endovascular treatment (e.g. aortic dissection or aneurysm, no arterial transfemoral access)
• Patient has history of contraindication for contrast medium.
• Patient is known to have infective endocarditis
• Patient's anticipated life expectancy is less than 6 Months12 months

Imaging exclusion criteria

• ExtracaranialExtracranial CT scan or MR angiography showing high grade stenosis expected to require acute stent placement (especially e.g. ICAACI stenting) during the procedure to get access to the occlusion
• CT or MRI with evidence of: Mass mass effect or intracranial tumor, or hypodensity on unenhanced CT and
• If CT perfusion is done per institutional standard: CBV drop on CBV maps on CTP, or, alternatively as with an ASPECT score of 0-2
• If DWI is done per institutional standard,: restricted diffusion on DWI with an ASPECT score of 0-2, or above 5

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Thrombectomy; Endovascular thrombectomy and best medical care	Device: Thrombectomy; Mechanical thrombectomy with state of the art thrombectomy devices (i.e. stent-retrievers, aspiration catheters). Devices will be used per instructions for use (IFU).; Other Names: Mechanical thrombectomy
Other: Best medical care; Best medical treatment	Other: Best medical care; Best medical treatment will be performed as detailed in established Standard Operating Procedures, following regional guidelines (American Heart Association (AHA), European Stroke Organisation (ESO), Deutsche Schlaganfall-Gesellschaft (DSG), local country, etc.). If applicable, the reason for iv tissue plasminogen activator (tPA) ineligibility has to be documented on the eCRF.; Other Names: Control group

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Clinical outcome-modified Rankin Scale at 90 days	The primary endpoint of the trial is the modified Rankin Scale (mRS) outcome at 90 days post-stroke. The primary effectiveness endpoint analysis is a chi-square test of the difference in linear trends in ordinal mRS outcomes at 90 days post-procedure between treatment groups ("mRS shift analysis").	90 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Independence - modified Rankin Scale≤2 at 90 days	Independent neurological outcomes with 90-day mRS≤2	90 days
Moderate Outcome - modified Rankin Scale≤3 at 90 days	Moderate neurological outcome with 90-day mRS≤3	90 days
Infarct volume 24 hours post procedure	Infarct volume at 24 hours on post-procedure imaging	18-36 hours
Infarct growth	Difference of infarct volume from infarct volume as predicted by pre-treatment imaging	18-36 hours
Functional neurological outcome at 12 months - modified Rankin Scale	Functional neurological outcome at 12 months (±14 days) after stroke (simplified modified Rankin Scale questionnaire, smRSq)	12 month
Quality of life - PROMIS-10	Patient-Reported Outcomes Measurement Information System (PROMIS)-10 questionaire at 90 (±14) days. PROMIS Global-10 short form consists of 10 items that assess general domains of health and functioning including overall physical health, mental health, social health, pain, fatigue, and overall perceived quality of life.	90 days
Quality of life - EQ-5D	Patient-reported functional health status and quality of life 90 (±14) days. EuroQol five-dimension scale. A standardised instrument created by the EuroQol Group as a measure of health outcome. EQ-5D is a descriptive system of health-related quality of life states consisting of 5 dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), each of which can take one of three responses reflecting severity (no problems/some or moderate problems/extreme problems).	90 days
Post-stroke depression - Patient Health Questionnaire-4	Post-stroke depression 90 (±14) days after stroke based on the Patient Health Questionnaire-4 (PHQ-4), Patient Health Questionnaire-4, Psychological distress in PHQ-4 is being rated based on 4 questions as none (0-2") mild (3-5) moderate (6-8) severe (9-12)	90 days
Parenchymal hemorrhage type 2	blood clots in >30% of the infarcted area with a substantial space-occupying effect.	90 days
modified Rankin Scale between 4-6	Death or dependency	12 month
Frequencies of Adverse Events (AE) in both treatment arms within the first 7 days	Serious AEs (SAEs), overall (all-cause mortality) and stroke-related death (i.e., related to intracranial bleeding, midline shift, brain herniation, progression of stroke symptoms, or systemic complications from stroke such as pneumonia).; Space-occupying infarction (malignant brain edema); New ischemic stroke	7 days
Serious AEs	Serious AEs (SAEs), overall (all-cause mortality) and stroke-related death (i.e., related to intracranial bleeding, midline shift, brain herniation, progression of stroke symptoms, or systemic complications from stroke such as pneumonia).	12 month
Space-occupying infarction	Malignant brain edema after treatment	18-36 hours
New ischemic stroke	New AIS after treatment	12 month
Symptomatic intracranial hemorrhage (sICH) at 24 (18-36) hours (CT or MRI)	sICH as defined in Safe Implementation of Treatments in Stroke-Monitoring Study (SITS-MOST); parenchymal hemorrhage type 2 (PH-2); Frequencies of Adverse Events (AE) in both treatment arms within the first 7 days after treatment; Serious AEs (SAEs), overall (all-cause mortality) and stroke-related death (i.e., related to intracranial bleeding, midline shift, brain herniation, progression of stroke symptoms, or systemic complications from stroke such as pneumonia).; Space-occupying infarction (malignant brain edema); New ischemic stroke	18-36 hours
Cost Utility Assessment	Assessment of costs from the time of randomization to the 12-months follow-up, including costs of hospitalization, institutionalized living, outpatient care, informal care provided by relatives and cost of lost productivity	12 month
Quality of life - PROMIS-10	Patient-Reported Outcomes Measurement Information System (PROMIS)-10 questionaire at 12 month (±14 days). PROMIS Global-10 short form consists of 10 items that assess general domains of health and functioning including overall physical health, mental health, social health, pain, fatigue, and overall perceived quality of life.	12 month
Quality of life - EQ-5D	Health related quality of life assessment at 12 months (±14 days). EuroQol five-dimension scale. A standardised instrument created by the EuroQol Group as a measure of health outcome. EQ-5D is a descriptive system of health-related quality of life states consisting of 5 dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), each of which can take one of three responses reflecting severity (no problems/some or moderate problems/extreme problems).	12 month
Post-stroke depression - Patient Health Questionnaire-4	Health related quality of life assessment at 12 months (±14 days) to assess post stroke depression - Patient Health Questionnaire-4 (PHQ-4) Psychological distress in PHQ-4 is being rated based on 4 questions as none (0-2") mild (3-5) moderate (6-8) severe (9-12)	12 month

Collaborators and Investigators

• Sponsor: University Hospital Heidelberg
• Collaborators: Charles University, Czech Republic; Karolinska University Hospital; Hospices Civils de Lyon; Oslo University Hospital; Aarhus University Hospital; CHU de Reims; Groupe Hospitalier Pitie-Salpetriere; Medical University Innsbruck; Universitätsklinikum Hamburg-Eppendorf; Epidemiological and Clinical Research Information Network; University Hospital, Martin; STROKE ALLIANCE FOR EUROPE; Eppdata GmbH Hamburg, Germany; International Consortium for Health Outcome Measurement, Inc.; Europan Society for Minimally Invasive Neurological Therapy
• Investigators: Study Chair: Götz Thomalla, MD, Coordination and Project Management Tension, Neurology, UKE Hamburg, Germany; Principal Investigator: Martin Bendszus, MD, Central Trial Management Tension, Neuroradiology, UHHeidelberg, Germany

Publications and helpful links

General Publications

• Roaldsen MB, Jusufovic M, Berge E, Lindekleiv H. Endovascular thrombectomy and intra-arterial interventions for acute ischaemic stroke. Cochrane Database Syst Rev. 2021 Jun 14;6(6):CD007574. doi: 10.1002/14651858.CD007574.pub3.
• Bendszus M, Bonekamp S, Berge E, Boutitie F, Brouwer P, Gizewski E, Krajina A, Pierot L, Randall G, Simonsen CZ, Zelenak K, Fiehler J, Thomalla G. A randomized controlled trial to test efficacy and safety of thrombectomy in stroke with extended lesion and extended time window. Int J Stroke. 2019 Jan;14(1):87-93. doi: 10.1177/1747493018798558. Epub 2018 Aug 29.
• Bendszus M, Fiehler J, Subtil F, Bonekamp S, Aamodt AH, Fuentes B, Gizewski ER, Hill MD, Krajina A, Pierot L, Simonsen CZ, Zelenak K, Blauenfeldt RA, Cheng B, Denis A, Deutschmann H, Dorn F, Flottmann F, Gellissen S, Gerber JC, Goyal M, Haring J, Herweh C, Hopf-Jensen S, Hua VT, Jensen M, Kastrup A, Keil CF, Klepanec A, Kurca E, Mikkelsen R, Mohlenbruch M, Muller-Hulsbeck S, Munnich N, Pagano P, Papanagiotou P, Petzold GC, Pham M, Puetz V, Raupach J, Reimann G, Ringleb PA, Schell M, Schlemm E, Schonenberger S, Tennoe B, Ulfert C, Valis K, Vitkova E, Vollherbst DF, Wick W, Thomalla G; TENSION Investigators. Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet. 2023 Nov 11;402(10414):1753-1763. doi: 10.1016/S0140-6736(23)02032-9. Epub 2023 Oct 11.
• van Horn N, Kniep H, Broocks G, Meyer L, Flottmann F, Bechstein M, Gotz J, Thomalla G, Bendszus M, Bonekamp S, Pfaff JAR, Dellani PR, Fiehler J, Hanning U. ASPECTS Interobserver Agreement of 100 Investigators from the TENSION Study. Clin Neuroradiol. 2021 Dec;31(4):1093-1100. doi: 10.1007/s00062-020-00988-x. Epub 2021 Jan 27.

Study record dates

Study Major Dates

• Study Start (Actual): June 20, 2018
• Primary Completion (Actual): May 31, 2023
• Study Completion (Actual): November 15, 2023

Study Registration Dates

• First Submitted: March 16, 2017
• First Submitted That Met QC Criteria: March 22, 2017
• First Posted (Actual): March 29, 2017

Study Record Updates

• Last Update Posted (Estimated): December 5, 2023
• Last Update Submitted That Met QC Criteria: November 28, 2023
• Last Verified: November 1, 2023

More Information

Terms related to this study

• Keywords: Mechanical thrombectomy; Endovascular thrombectomy
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Stroke
• Other Study ID Numbers: TENSION

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes
• product manufactured in and exported from the U.S.: Yes