{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T21:51:35Z","timestamp":1790373095580,"version":"4.1.0"},"reference-count":34,"publisher":"Oxford University Press (OUP)","issue":"6","license":[{"start":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T00:00:00Z","timestamp":1781740800000},"content-version":"vor","delay-in-days":17,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"EU Horizon 2020 research and innovation programme","award":["754640"],"award-info":[{"award-number":["754640"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,6,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Traditional endpoints in acute ischaemic stroke trials, most commonly the mRS, incompletely capture the full spectrum of patient outcomes. The win ratio (WR) is a hierarchically structured composite outcome measure that prioritises endpoints according to clinical importance. In this study, we applied win statistics to investigate which components drive the overall treatment effect.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patients and methods<\/jats:title>\n                    <jats:p>Of 253 patients in the TENSION (Efficacy and safety of ThrombEctomy iN Stroke with extended leSION and extended time window) trial, 125 were randomised to EVT\u00a0+\u00a0BMT and 128 to BMT alone. Endpoints were ranked hierarchically: (1) time to death, (2) mRS at 12\u00a0months, (3) occurrence of any serious adverse event and (4) EuroQOL 5-dimension scores at 12\u00a0months. Outcomes were analysed using win statistics.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The overall WR was 1.61 (95% CI, 1.19\u20132.18; P\u00a0=\u00a0.002), indicating a relative frequency of wins for EVT\u00a0+\u00a0BMT of approximately 60% among untied pairwise comparisons. The win difference was 22.8% (95% CI, 8.3%\u201336.3%; P\u00a0=\u00a0.002), of which 15.7% were attributable to survival. Win ratios were consistent across prespecified subgroups, including both sexes, age\u00a0\u2264\u00a080\u00a0years, baseline mRS 0\u20131, conscious patients, ASPECTS 5 and M1 occlusions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>The WR provides an informative complement to conventional mRS-based analyses in acute ischaemic stroke trials. Our hierarchical composite outcome analysis demonstrated how ordering of hierarchical components affects the resulting estimates, with the predominant treatment effect in TENSION being driven by improved survival.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>These findings support the complementary use of hierarchical composite outcomes in future neurointerventional trials.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/esj\/aakag063","type":"journal-article","created":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T23:37:45Z","timestamp":1781825865000},"source":"Crossref","is-referenced-by-count":1,"title":["Hierarchical composite outcomes in acute ischaemic stroke with large infarct: a win ratio analysis of the TENSION trial"],"prefix":"10.1093","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0082-2026","authenticated-orcid":false,"given":"Olga","family":"Ciobanu-Caraus","sequence":"first","affiliation":[{"name":"Interventional Neuroradiology, Department of Neuroradiology, Heidelberg University Hospital , Heidelberg ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philip","family":"Heesen","sequence":"additional","affiliation":[{"name":"Interventional Neuroradiology, Department of Neuroradiology, Heidelberg University Hospital , Heidelberg ,","place":["Germany"]},{"name":"Department of Biostatistics at the Epidemiology, Biostatistics and Prevention Institute, University of Zurich , Zurich ,","place":["Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael D","family":"Hill","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurosciences, Hotchkiss Brain Institute, Health Science Centre, University of Calgary & Foothills Medical Centre , Calgary, Alberta ,","place":["Canada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susanne","family":"Bonekamp","sequence":"additional","affiliation":[{"name":"Interventional Neuroradiology, Department of Neuroradiology, Heidelberg University Hospital , Heidelberg ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8533-7478","authenticated-orcid":false,"given":"Jens","family":"Fiehler","sequence":"additional","affiliation":[{"name":"Klinik und Poliklinik f\u00fcr Neuroradiologische Diagnostik und Intervention, Universit\u00e4tsklinikum Hamburg-Eppendorf , Hamburg ,","place":["Germany"]},{"name":"Eppdata GmbH , Hamburg ,","place":["Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne Hege","family":"Aamodt","sequence":"additional","affiliation":[{"name":"Department of Neurology, Oslo University Hospital , Oslo ,","place":["Norway"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Blanca","family":"Fuentes","sequence":"additional","affiliation":[{"name":"Department of Neurology and Stroke Centre, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Aut\u00f3noma de Madrid) , Madrid ,","place":["Spain"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elke R","family":"Gizewski","sequence":"additional","affiliation":[{"name":"Department of Radiology, Medical University Innsbruck , Innsbruck ,","place":["Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonin","family":"Krajina","sequence":"additional","affiliation":[{"name":"Department of Radiology, Faculty of Medicine in Hradec Kr\u00e1lov\u00e9, Charles University , Hradec Kr\u00e1lov\u00e9 ,","place":["Czech 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