Abstract
Background
Endovascular thrombectomy (EVT) is recommended in medically eligible patients with
large vessel occlusions (LVO) within 24 hours of symptom onset. While there is evidence
that EVT ≥24h after last known well (LKW) is associated with favorable outcomes in
patients who meet DAWN/DEFUSE-3 criteria, it is unknown if more liberal criteria can
be applied.
Methods
A single center, prospective observational cohort of consecutive adult stroke patients
was queried for symptomatic occlusions of the internal carotid (ICA) or proximal middle
cerebral (M1) arteries (October 2019-January 2022), with a National Institutes of
Health Stroke Scale (NIHSS) ≥6, pre-stroke modified Rankin Scale (mRS) 0-2, and Alberta
Stroke Program Early Computed Tomography Scale score 3-10. These inclusion criteria
were extrapolated from recently published data indicating a benefit with EVT with
more liberal patient selection. Patients who underwent EVT ≥24h after LKW were compared
against those treated medically. The primary outcome was a good functional outcome
(90-day mRS 0-2), which was evaluated using multivariable logistic regression.
Results
Of the 27 included patients, the median age was 65y (IQR 49-76) with a median NIHSS
of 15 (IQR 8-26), and 17 (63.0%) underwent EVT (median LKW-to-puncture 35.5h (IQR
26.9-65.8h). The primary outcome was no different with EVT in unadjusted regression
(OR 1.17, 95%CI 0.17-8.09), and there remained no association across all multivariable
models tested. Age, pre-stroke disability, and M1 occlusions were non-significantly
associated with the primary outcome (p>0.05). There was a non-significant trend indicating
a favorable shift in 90-day mRS with EVT (proportional OR 2.04, 95%CI 0.44-9.48).
Conclusions
Using more liberal inclusion criteria for EVT in the ultra-extended window, there
was no statistically significant difference in the rate of good functional outcome
with EVT. Larger studies are called upon to evaluate outcomes when more liberal criteria
are used to assess thrombectomy eligibility.
Key Words
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References
- Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2019; 50: e344-e418
- Thrombectomy for anterior circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis.Lancet. 2022; 399: 249-258
- Assessment of optimal patient selection for endovascular thrombectomy beyond 6 hours after symptom onset: a pooled analysis of the AURORA database.JAMA Neurol. 2021; 78: 1064-1071
- Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry.Ther Adv Neurol Disord. 2019; 121756286419835708
- Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.Lancet. 2016; 387: 1723-1731
- Extending the stroke treatment window beyond DAWN in patients with very slow progressor type collaterals: how far can we go?.J Cerebrovasc Endovasc Neurosurg. 2021; 23: 354-358
- A case of mechanical thrombectomy for acute occlusion of the left internal carotid artery later than 24 hours after onset.J Neuroendovasc Therapy. 2021; ([Internet]advpub. Available from:)https://doi.org/10.5797/jnet.cr.2020-0079
- Thrombectomy in DAWN- and DEFUSE-3-ineligible patients: a subgroup analysis from the BEST prospective cohort study [Internet].Neurosurgery. 2020; 86 (Available from:): E156-E163https://doi.org/10.1093/neuros/nyz485
- Endovascular thrombectomy >24-hr from stroke symptom onset [Internet].Front Neurol. 2018; 9 (Available from:)https://doi.org/10.3389/fneur.2018.00501
- Thrombectomy 24 hours after stroke: beyond DAWN.J Neurointerv Surg. 2018; 10: 1039-1042
- Endovascular treatment after stroke due to large vessel occlusion for patients presenting very late from time last known well.JAMA Neurol. 2020; ([Internet]Available from:)https://doi.org/10.1001/jamaneurol.2020.2804
- Prestroke disability and outcome after thrombectomy for emergent anterior circulation large vessel occlusion stroke.Neurology. 2021; 97: e1914-e1919
- Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform. 2009; 42: 377-381
- Falling stroke rates during COVID-19 pandemic at a Comprehensive Stroke Center: Cover title: Falling stroke rates during COVID-19.J Stroke Cerebrovasc Dis. 2020; ([Internet] Available from:)
- Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group.AJNR Am J Neuroradiol. 1993; 14: 3-13
- Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke.Ann Neurol. 1992; 32: 78-86
- Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study.Lancet. 2007; 369: 275-282
- Extending thrombolysis to 4\textperiodcentered 5–9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data.Lancet. 2019; 394: 139-147
- Endovascular therapy for acute stroke with a large ischemic region.N Engl J Med. 2022; 386: 1303-1313
- Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.N Engl J Med. 2018; 378: 708-718
- Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.N Engl J Med. 2018; 378: 11-21
- Noncontrast computed tomography vs computed tomography perfusion or magnetic resonance imaging selection in late presentation of stroke with large-vessel occlusion.JAMA Neurol. 2022; 79: 22-31
- Clinical course of acute ischemic stroke due to medium vessel occlusion with and without intravenous Alteplase treatment.Stroke. 2020; 51: 3232-3240
- Abstract 36: endovascular thrombectomy beyond 24 hours from last known well: a pooled multicenter international cohort.Stroke. 2022; 53: A36
- Thrombectomy in extensive stroke may not be beneficial and is associated with increased risk for hemorrhage.Stroke. 2021; 52: 3109-3117
- Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST): an open-label, randomised controlled trial.Lancet Neurol. 2020; 19: 115-122
- Endovascular Therapy for stroke due to basilar-artery occlusion [Internet].J Emerg Med. 2021; 61: 116https://doi.org/10.1016/j.jemermed.2021.06.003
- Prevalence and temporal distribution of fast and slow progressors of infarct growth in large vessel occlusion stroke [Internet].Stroke. 2019; 50: 2238-2240https://doi.org/10.1161/strokeaha.118.024035
- Noncontrast CT versus perfusion-based core estimation in large vessel occlusion: the blood pressure after endovascular stroke therapy study.J Neuroimaging. 2020; 30: 219-226
Article info
Publication history
Published online: January 18, 2023
Accepted:
December 18,
2022
Received in revised form:
November 21,
2022
Received:
August 23,
2022
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106952
Copyright
© 2022 Elsevier Inc. All rights reserved.
