Outcomes following thrombectomy for acute large vessel occlusion beyond 24 hours or with unknown time of onset

Zachary Iezzi; Pratit Patel; Jared Wolfe; Justin Tiongson; Nicholas Vigilante; Scott Kamen; Mary Penckofer; Jane Khalife; James E Siegler

doi:10.1016/j.jstrokecerebrovasdis.2022.106952

Outcomes following thrombectomy for acute large vessel occlusion beyond 24 hours or with unknown time of onset

J Stroke Cerebrovasc Dis. 2023 Mar;32(3):106952. doi: 10.1016/j.jstrokecerebrovasdis.2022.106952. Epub 2023 Jan 19.

Authors

Zachary Iezzi¹, Pratit Patel², Jared Wolfe³, Justin Tiongson³, Nicholas Vigilante³, Scott Kamen³, Mary Penckofer³, Jane Khalife², James E Siegler⁴

Affiliations

¹ Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA.
² Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA.
³ Cooper Medical School of Rowan University, Camden, NJ, USA.
⁴ Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA. Electronic address: siegler.james@gmail.com.

PMID: 36669375
DOI: 10.1016/j.jstrokecerebrovasdis.2022.106952

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.

Keywords: Endovascular treatment; Extended window; Large vessel occlusion; Outcomes research; Thrombectomy.

Publication types

Observational Study

MeSH terms

Aged
Brain Ischemia* / diagnostic imaging
Brain Ischemia* / therapy
Endovascular Procedures* / adverse effects
Endovascular Procedures* / methods
Humans
Retrospective Studies
Stroke* / diagnostic imaging
Stroke* / therapy
Thrombectomy / adverse effects
Thrombectomy / methods
Tomography, X-Ray Computed
Treatment Outcome