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Larcipretti ALL, Gomes FC, Dagostin CS, Nager GB, Udoma-Udofa OC, Pontes JPM, de Oliveira JS, Bannach MDA. Is time really brain in stroke therapy?: A meta-analysis of mechanical thrombectomy up to 155 h post ictus. Acta Neurochir (Wien) 2024; 166:195. [PMID: 38668855 DOI: 10.1007/s00701-024-06070-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/04/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND AND OBJECTIVES Mechanical thrombectomy (MT) has been established as the gold standard of treatment for patients with Acute Ischemic Stroke (AIS) who present up to 6 h after the onset of the stroke. Recently, the DEFUSE-3 and DAWN trials established the safety of starting the MT procedure up to 16 and 24 h after the patient was last seen well, respectively. The purpose of this study is to assess the safety and functional effects of thrombectomy in individuals with AIS detected at a late stage (> 24 h). MATERIALS AND METHODS PubMed, Web of Science, Embase, and Cochrane databases were thoroughly searched for research on MT in patients in the extremely late time window after AIS. The primary outcomes were symptomatic cerebral hemorrhage, 90-day mortality, Thrombolysis in Cerebral Infarction (TICI) 2b-3, and Modified Rankin Scale (mRS) 0-2. RESULTS Our study included fifteen studies involving a total of 1,221 patients who presented with AIS and an extended time window. The primary outcome of interest was the favorable functional outcome, mRS 0-2 at 90 days. The pooled proportion for this outcome was 45% (95% confidence interval 34-58%). Other outcomes included the TICI 2b or 3 (successful recanalization), which was reported in 12 studies and had a 79% incidence in the study population (95% CI 68-87%). Complications included: symptomatic intracranial hemorrhage (sICH), which revealed an incidence of 7% in the study population (95% CI 5-10%); and 90-day mortality, which reported a 27% incidence (95% CI 24-31%). In addition, we conducted a comparative analysis between endovascular treatment and standard medical therapy. CONCLUSION Our meta-analysis provides evidence that supports the need of further randomized and prospective clinical trials to better assess the effectiveness and safety of MT in these patients.
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Affiliation(s)
| | | | | | - Gabriela Borges Nager
- Faculty of Medicine, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Julia Pereira Muniz Pontes
- Department of Surgical Specialties, Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil
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Ademola A, Bala F, Menon BK, Thornton J, Casetta I, Nannoni S, Goyal M, Herlihy D, Fainardi E, Power S, Saia V, Hegarty A, Pracucci G, Demchuk A, Mangiafico S, Boyle K, Michel P, Hildebrand KA, Sajobi TT, Hill MD, Toni D, Murphy S, Kim BJ, Almekhlafi MA. Workflow and Outcome of Thrombectomy in Late Time Window: A Pooled Multicenter Analysis. Can J Neurol Sci 2024:1-7. [PMID: 38639107 DOI: 10.1017/cjn.2024.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND We investigated the impact of workflow times on the outcomes of patients treated with endovascular thrombectomy (EVT) in the late time window. METHODS Individual patients' data who underwent EVT in the late time window (onset to imaging >6 hours) were pooled from seven registries and randomized clinical trials. Multiple time intervals were analyzed. Mixed-effects logistic regression was used to estimate the likelihood of functional independence at 90 days (modified Rankin Scale 0-2). Mixed-effects negative binomial regression was used to evaluate the relationship between patient characteristics and workflow time intervals. RESULTS 608 patients were included. The median age was 70 years (IQR: 58-71), 307 (50.5%) were female, and 310 (53.2%) had wake-up strokes. Successful reperfusion was achieved in 493 (81.2%) patients, and 262 (44.9%) achieved 90-day mRS 0-2. The estimated odds of functional independence decreased by 13% for every 30 minute delay from emergency department (ED) arrival to imaging time and by 7% from ED arrival to the end of EVT in the entire cohort. Also, the estimated odds of functional independence decreased by 33% for every 30 minute delay in the interval from arterial puncture to end of EVT, 16% in the interval from arrival in ED to end of EVT and 6% in the interval from stroke onset to end of EVT among patients who had a wake-up stroke. CONCLUSION Faster workflow from ED arrival to end of EVT is associated with improved functional independence among stroke patients treated in the late window.
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Affiliation(s)
- Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - John Thornton
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ilaria Casetta
- Clinica Neurologica, University of Ferrara, Ferrara, Italy
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Darragh Herlihy
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Sarah Power
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Valentina Saia
- Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Aidan Hegarty
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | | | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | | | - Karl Boyle
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Kevin A Hildebrand
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Danilo Toni
- Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Mohammed A Almekhlafi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
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3
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Rodriguez-Calienes A, Hassan AE, Siegler JE, Galecio-Castillo M, Farooqui M, Jumaa MA, Janjua N, Divani AA, Ribo M, Abraham M, Petersen NH, Fifi J, Guerrero WR, Malik AM, Nguyen TN, Sheth S, Yoo AJ, Linares G, Lu Y, Vivanco-Suarez J, Ortega-Gutierrez S. Mechanical thrombectomy beyond 24 hours from last known well in tandem lesions: A multicenter cohort study. Interv Neuroradiol 2023:15910199231196960. [PMID: 37642978 DOI: 10.1177/15910199231196960] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND While recent studies suggest a benefit of mechanical thrombectomy (MT) for the treatment of patients with isolated large vessel occlusions presenting after 24 hours from the last known well (LKW), the effect of MT for acute cervical tandem lesions (TLs) beyond 24 hours remains unknown. We aimed to evaluate the safety and effectiveness of MT beyond 24 hours of LKW in patients with TLs. METHODS We conducted a subanalysis study of patients with anterior circulation TL enrolled in a large, multicenter registry between January 2015 and December 2020. Patients were divided into 2 groups: MT beyond 24 hours versus MT 0-24-hour window. Outcomes of interest were functional independence (90-day modified Rankin scale 0-2), complete reperfusion (modified thrombolysis in cerebral infarction 3), delta NIH Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), parenchymal hematoma 2 (PH2), in-hospital mortality, and 90-day mortality. Inverse probability of treatment weighting (IPTW) was used to balance the groups. RESULTS Overall, 589 participants were included, with 33 treated beyond 24 hours and 556 treated in the 0-24-hour window. After IPTW, we found no significant difference in the rates of achieving functional independence (odds ratio (OR) = 0.51; 95% confidence interval (CI) 0.22-1.16; p = 0.108), complete reperfusion (OR = 1.35; 95% CI 0.60-3.05; p = 0.464), sICH (OR = 1.96; 95% CI 0.37-10.5; p = 0.429), delta NIHSS (β = -3.61; 95% CI -8.11 to 0.87; p = 0.114), PH2 (OR = 1.46; 95% CI 0.29-7.27; p = 0.642), in-hospital mortality (OR = 1.74; 95% CI 0.52-5.86; p = 0.370), or 90-day mortality (OR = 1.37; 95% CI 0.49-3.83; p = 0.544) across both time windows. CONCLUSIONS Our results suggest that MT appears to benefit patients with TLs beyond 24 hours from LKW. Future prospective studies are warranted.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Cientifica del Sur, Lima, Peru
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center / University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Waldo R Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Amer M Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
| | - Sunil Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | | | - Yujing Lu
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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4
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Zhu CM, Li Q, Zeng W, Liu AF, Zhou J, Zhang M, Jiang YF, Li X, Jiang WJ. Safety and efficacy of endovascular recanalization in patients with mild anterior stroke due to large-vessel occlusion exceeding 24 hours. Int J Neurosci 2023:1-10. [PMID: 37458211 DOI: 10.1080/00207454.2023.2236781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/04/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Endovascular recanalization (ER) has demonstrated efficacy as a treatment modality for patients presenting with acute ischemic stroke (AIS) caused by large-vessel occlusion (LVO) within a 24-hour timeframe. Nevertheless, the safety and effectiveness of ER in patients with a time of onset exceeding 24 h remain uncertain. OBJECTIVE To evaluate the safety and efficacy of ER treatment for mild ischemic stroke beyond 24-h from symptom onset. METHODS A retrospectively maintained database of mild AIS due to LVO from March2018 to September 2022 at a comprehensive stroke center was screened.Patients received ER or standard medical therapies (SMT) for anterior circulation AIS due to LVO > 24-h were selected. RESULTS We included 47 LVO patients with mild AIS beyond 24-h who suffered neurological deterioration (ND). 34 of these patients underwent ER, the other 13 received SMT. The technical success rate of recanalization was 82.4% (28/34). Patients received ER had significantly lower NIHSS score at discharge and 90-day mRS score (p = 0.028, p = 0.037, respectively) compared to SMT. In addition, they had significantly lower 90-day recurrence of ischemic stroke and lower incidence of moderate-severe stroke (with a NIHSS score at least 5) (p = 0.037, p = 0.033). There were 4 patients (11.7%) had perioperative complications, and no symptomatic intracranial hemorrhage occurred. CONCLUSION ER treatment for mild AIS due to LVO encountered ND was generally safe and effective, even beyond 24-h, and resulted in a good prognosis and lower 90-day recurrence compared to SMT.
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Affiliation(s)
- Can-Min Zhu
- Department of Medicine, Soochow University School of Medicine, Suzhou, Jiang-su, China
- Department of Neurology, The First people's Hospital of Jiangxia District, Wuhan, Hu-bei, China
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Qiang Li
- Department of Neurology, Wuhan Fifth Hospital, Jianghan University School of Medicine, Wuhan, Hu-bei, China
| | - Wei Zeng
- Department of Neurology, Wuhan Fifth Hospital, Jianghan University School of Medicine, Wuhan, Hu-bei, China
| | - Ao-Fei Liu
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Ji Zhou
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Mei Zhang
- Department of Neurology, Wuhan Fifth Hospital, Jianghan University School of Medicine, Wuhan, Hu-bei, China
| | - Yuan-Feng Jiang
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Xia Li
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Wei-Jian Jiang
- Department of Medicine, Soochow University School of Medicine, Suzhou, Jiang-su, China
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
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5
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Rodriguez-Calienes A, Galecio-Castillo M, Vivanco-Suarez J, Mohamed GA, Toth G, Sarraj A, Pujara D, Chowdhury AA, Farooqui M, Ghannam M, Samaniego EA, Jovin TG, Ortega-Gutierrez S. Endovascular thrombectomy beyond 24 hours from last known well: a systematic review with meta-analysis. J Neurointerv Surg 2023:jnis-2023-020443. [PMID: 37355251 DOI: 10.1136/jnis-2023-020443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Different studies have demonstrated the benefit of endovascular treatment (EVT) up to 24 hours after acute ischemic stroke (AIS) onset. Recent cohort observational studies suggest that patients with large vessel occlusion AIS may benefit from EVT beyond 24 hours from the last known well (LKW) when adequately selected. We aimed to examine the safety and efficacy of EVT beyond 24 hours from LKW using a meta-analysis of all the literature available. METHODS A systematic search from inception to April 2023 was conducted for studies including AIS patients with EVT beyond 24 hours from LKW in Medline, Embase, Scopus, and Web of Science. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0-2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Data were pooled using a random-effects model. RESULTS Twelve studies with 894 patients were included. The rate of favorable functional outcome was 40% (95% CI 31% to 49%; I2=76%). The rate of successful reperfusion was 83% (95% CI 80% to 85%; I2=0%). The sICH rate was 7% (95% CI 5% to 9%; I2=0%) and the 90-day mortality rate was 28% (95% CI 24% to 33%; I2=0%). There was no significant difference in favorable outcomes (OR=0.69; 95% CI 0.41 to 1.14) and 90-day mortality (OR=1.35; 95% CI 0.90 to 2.00) among patients who underwent EVT <24 hours versus >24 hours. CONCLUSIONS EVT beyond 24 hours from LKW may achieve favorable clinical outcomes and high reperfusion rates, with acceptable intracranial hemorrhage rates in selected patients. Considering the current certainty of the evidence and heterogenous individual study results, larger prospective trials are warranted.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru
| | | | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ghada A Mohamed
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Deep Pujara
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Aj A Chowdhury
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Malik Ghannam
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Dhillon PS, Butt W, Podlasek A, Barrett E, McConachie N, Lenthall R, Nair S, Malik L, James MA, Dineen RA, England TJ. Endovascular thrombectomy beyond 24 hours from ischemic stroke onset: a propensity score matched cohort study. J Neurointerv Surg 2023; 15:233-237. [PMID: 35169031 DOI: 10.1136/neurintsurg-2021-018591] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/30/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The safety and functional outcome of endovascular thrombectomy (EVT) in the very late (VL; >24 hours) time window from ischemic stroke onset remains undetermined. METHODS Using data from a national stroke registry, we used propensity score matched (PSM) individual level data of patients who underwent EVT, selected with CT perfusion or non-contrast CT/CT angiography, between October 2015 and March 2020. Functional and safety outcomes were assessed in both late (6-24 hours) and VL time windows. Subgroup analysis was performed of imaging selection modality in the VL time window. RESULTS We included 1150 patients (late window: 1046 (208 after PSM); VL window: 104 (104 after PSM)). Compared with EVT treatment initiation between 6 and 24 hours, patients treated in the VL window had similar modified Rankin Scale (mRS) scores at discharge (ordinal shift; common OR=1.08, 95% CI 0.69 to 1.47, p=0.70). No significant differences in achieving good functional outcome (mRS ≤2 at discharge; 28.8% (VL) vs 29.3% (late), OR=0.97, 95% CI 0.58 to 1.64, p=0.93), successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b-3) (p=0.77), or safety outcomes of symptomatic intracranial hemorrhage (p=0.43) and inhospital mortality (p=0.23) were demonstrated. In the VL window, there was no significant difference in functional outcome among patients selected with perfusion versus those selected without perfusion imaging (common OR=1.38, 95% CI 0.81 to 1.76, p=0.18). CONCLUSION In this real world study, EVT beyond 24 hours from stroke onset or last known well appeared to be feasible, with comparable safety and functional outcomes to EVT initiation between 6 and 24 hours. Randomized trials assessing the efficacy of EVT in the VL window are warranted, but may only be feasible with a large international collaborative approach.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK .,NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Emma Barrett
- Department of Research and Innovation (Medical Statistics), Manchester University NHS Foundation Trust, Manchester, UK.,Centre for Biostatistics, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin A James
- Exeter Medical School, University of Exeter, Exeter, UK.,Stroke, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Robert A Dineen
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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7
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Sarraj A, Kleinig TJ, Hassan AE, Portela PC, Ortega-Gutierrez S, Abraham MG, Manning NW, Siegler JE, Goyal N, Maali L, Blackburn S, Wu TY, Blasco J, Renú A, Sangha NS, Arenillas JF, McCullough-Hicks ME, Wallace A, Gibson D, Pujara DK, Shaker F, de Lera Alfonso M, Olivé-Gadea M, Farooqui M, Vivanco Suarez JS, Iezzi Z, Khalife J, Lechtenberg CG, Qadri SK, Moussa RB, Abdulrazzak MA, Almaghrabi TS, Mir O, Beharry J, Krishnaiah B, Miller M, Khalil N, Sharma GJ, Katsanos AH, Fadhil A, Duncan KR, Hu Y, Martin-Schild SB, Tsivgoulis GK, Cordato D, Furlan A, Churilov L, Mitchell PJ, Arthur AS, Parsons MW, Grotta JC, Sitton CW, Ribo M, Albers GW, Campbell BCV. Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well: The SELECT Late Study. JAMA Neurol 2023; 80:172-182. [PMID: 36574257 PMCID: PMC9857518 DOI: 10.1001/jamaneurol.2022.4714] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/27/2022] [Indexed: 12/28/2022]
Abstract
Importance The role of endovascular thrombectomy is uncertain for patients presenting beyond 24 hours of the time they were last known well. Objective To evaluate functional and safety outcomes for endovascular thrombectomy (EVT) vs medical management in patients with large-vessel occlusion beyond 24 hours of last known well. Design, Setting, and Participants This retrospective observational cohort study enrolled patients between July 2012 and December 2021 at 17 centers across the United States, Spain, Australia, and New Zealand. Eligible patients had occlusions in the internal carotid artery or middle cerebral artery (M1 or M2 segment) and were treated with EVT or medical management beyond 24 hours of last known well. Interventions Endovascular thrombectomy or medical management (control). Main Outcomes and Measures Primary outcome was functional independence (modified Rankin Scale score 0-2). Mortality and symptomatic intracranial hemorrhage (sICH) were safety outcomes. Propensity score (PS)-weighted multivariable logistic regression analyses were adjusted for prespecified clinical characteristics, perfusion parameters, and/or Alberta Stroke Program Early CT Score (ASPECTS) and were repeated in subsequent 1:1 PS-matched cohorts. Results Of 301 patients (median [IQR] age, 69 years [59-81]; 149 female), 185 patients (61%) received EVT and 116 (39%) received medical management. In adjusted analyses, EVT was associated with better functional independence (38% vs control, 10%; inverse probability treatment weighting adjusted odds ratio [IPTW aOR], 4.56; 95% CI, 2.28-9.09; P < .001) despite increased odds of sICH (10.1% for EVT vs 1.7% for control; IPTW aOR, 10.65; 95% CI, 2.19-51.69; P = .003). This association persisted after PS-based matching on (1) clinical characteristics and ASPECTS (EVT, 35%, vs control, 19%; aOR, 3.14; 95% CI, 1.02-9.72; P = .047); (2) clinical characteristics and perfusion parameters (EVT, 35%, vs control, 17%; aOR, 4.17; 95% CI, 1.15-15.17; P = .03); and (3) clinical characteristics, ASPECTS, and perfusion parameters (EVT, 45%, vs control, 21%; aOR, 4.39; 95% CI, 1.04-18.53; P = .04). Patients receiving EVT had lower odds of mortality (26%) compared with those in the control group (41%; IPTW aOR, 0.49; 95% CI, 0.27-0.89; P = .02). Conclusions and Relevance In this study of treatment beyond 24 hours of last known well, EVT was associated with higher odds of functional independence compared with medical management, with consistent results obtained in PS-matched subpopulations and patients with presence of mismatch, despite increased odds of sICH. Our findings support EVT feasibility in selected patients beyond 24 hours. Prospective studies are warranted for confirmation.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Timothy J. Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, Texas
| | | | | | - Michael G. Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Nathan W. Manning
- Department of Neurosurgery, Liverpool Hospital, Sydney, New South Wales, Australia
| | - James E. Siegler
- Department of Neurology, Cooper Neurological Institute, Camden, New Jersey
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis
| | - Laith Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Spiros Blackburn
- Department of Neurosurgery, University of Texas Health Sciences Center, Houston
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jordi Blasco
- Department of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Arturu Renú
- Department of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Navdeep S. Sangha
- Department of Neurology, Stroke and Telestroke, Kaiser Permanente, Los Angeles, California
| | - Juan F. Arenillas
- Department of Neurology, Hospital Clínico Universitario – University of Valladolid, Valladolid, Spain
| | | | - Adam Wallace
- Department of Neurointerventional Surgery, Ascension Wisconsin, Milwaukee
| | - Daniel Gibson
- Department of Neurointerventional Surgery, Ascension Wisconsin, Milwaukee
| | - Deep K. Pujara
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Faris Shaker
- Department of Neurosurgery, University of Texas Health Sciences Center, Houston
| | - Mercedes de Lera Alfonso
- Department of Neurology, Hospital Clínico Universitario – University of Valladolid, Valladolid, Spain
| | - Marta Olivé-Gadea
- Department of Neurology, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Mudassir Farooqui
- Neurointerventional Research Lab, University of Iowa Hospitals and Clinics, Iowa City
| | | | - Zachary Iezzi
- Department of Neurology, Cooper Neurological Institute, Camden, New Jersey
| | - Jane Khalife
- Department of Neurology, Cooper Neurological Institute, Camden, New Jersey
| | | | - Syed K. Qadri
- Department of Neurology, University of Texas Health Sciences Center, Houston
| | - Rami B. Moussa
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | | | - Osman Mir
- Department of Neurology, Texas Stroke Institute, Dallas
| | - James Beharry
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Balaji Krishnaiah
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis
| | - Megan Miller
- Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Najwa Khalil
- Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Gagan J. Sharma
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Neurology, University of Melbourne, Parkville, Victoria, Australia
| | - Aristeidis H. Katsanos
- Department of Neurology, McMaster University and Population Health Research Institute, Toronto, Ontario, Canada
| | - Ali Fadhil
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kelsey R. Duncan
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Yin Hu
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Sheryl B. Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, New Orleans, Louisiana
| | - Georgios K. Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Dennis Cordato
- Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Anthony Furlan
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Leonid Churilov
- Department of Biostatistics, University of Melbourne, Parkville, Victoria, Australia
| | - Peter J. Mitchell
- Department of Radiology, NeuroIntervention Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Adam S. Arthur
- Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee
| | - Mark W. Parsons
- Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - James C. Grotta
- Department of Neurology, Memorial Hermann Hospital – Texas Medical Center, Houston
| | - Clark W. Sitton
- Department of Radiology and Neuroradiology, University of Texas Health Sciences Center, Houston
| | - Marc Ribo
- Department of Neurology, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | | | - Bruce C. V. Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Vinarsky V, Sun LR, Yedavalli VS, Schleifer L, Arthur K, Hui F, Harrar DB. Case Report: Successful Anterior Circulation Thrombectomy After 24 Hours in An Adolescent. Pediatr Neurol 2023; 143:64-67. [PMID: 37003190 DOI: 10.1016/j.pediatrneurol.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 12/14/2022] [Accepted: 01/23/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Arterial ischemic stroke in children comes with the potential for morbidity and mortality and can result in high cost of care and decreased quality of life among survivors. Children with arterial ischemic stroke are increasingly being treated with mechanical thrombectomy, but little is known about the risks and benefits 24 hours after a patient's last known well (LKW) time. METHODS A 16-year-old female presented with acute onset of dysarthria and right hemiparesis with LKW time 22 hours prior. Pediatric National Institutes of Health Stroke Scale score was 12. Magnetic resonance imaging showed diffusion restriction and T2 hyperintensity primarily in the left basal ganglia. Magnetic resonance angiography revealed left M1 occlusion. Arterial spin labeling showed a large apparent perfusion deficit. She underwent thrombectomy with TICI3 recanalization 29.5 hours after LKW time. RESULTS At 2-month follow-up, her examination showed moderate right-hand weakness and mild diminished sensation of the right arm. CONCLUSIONS Adult thrombectomy trials include patients up to 24 hours from their LKW time and suggest that some patients maintain a favorable perfusion profile for over 24 hours. Without intervention many go on to experience infarct expansion. The persistence of a favorable perfusion profile likely reflects robust collateral circulation. We hypothesized our patient was relying on collateral circulation to maintain the noninfarcted areas of her left middle cerebral artery territory. Owing to concern for eventual collateral failure, thrombectomy outside of the 24-hour window was performed. This case serves as a call to action to better understand the impact of collateral circulation on cerebral perfusion in children with large vessel occlusions and delineate which children may benefit from thrombectomy in a delayed time window.
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