Abstract WMP20: Effect of Leukoaraiosis on Outcomes of Mechanical Thrombectomy and Proposed New Leukoaraiosis-Aspects Score

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Waleed Brinjikji ◽  
John Benson ◽  
Alejandro A Rabinstein ◽  
David F Kallmes
Keyword(s):  
Mechanical Thrombectomy ◽  
Primary Outcome Measure ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Endovascular Recanalization ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Fazekas Scale

Background and Purpose: Leukoaraiosis is a poor prognostic marker for patients with acute ischemic stroke (AIS). This study sought to assess if severity of leukoaraiosis is associated with outcome in patients with AIS following endovascular thrombectomy, and to propose a leukoaraiosis-related modification to the ASPECTS score to improve its predictive value for good outcome. Methods: We analyzed consecutive patients with AIS that underwent mechanical thrombectomy for anterior circulation large vessel occlusion at our comprehensive stroke center. Leukoaraiosis burden was graded using the Fazekas scale (combined scores from two locations categorically divided into no leukoaraiosis (score = 0), mild (1-2), moderate (3-4) and severe (5-6)). The primary outcome measure was 90-day mRS. A proposed Leukoaraiosis-ASPECTS (“L-ASPECTS”) was calculated by subtracting values from the traditional ASPECT based on leukoaraiosis severity (1 point subtracted if mild, 2 if moderate, 3 if severe). Results: Of 174 included patients, 89 (51.2%) were female; average age was 68.0±9.1. 28 (16.1%) had no leukoaraiosis, 66 (37.9%) had mild, 62 (35.6%) had moderate, and 18 (10.3%) had severe. Leukoaraiosis severity was associated with worse 90-day mRS among all patients (p=0.0005) as well as those that were successfully revascularized (p=0.0002). A multivariate analysis confirmed that leukoaraiosis burden was associated with worse 90-day mRS among all patients (mild: p=0.006; moderate: p=0.002; severe: p=0.03), as well as those that underwent successful thrombectomies (p=0.005). Both L-ASPECTS and ASPECTS were associated with poor outcomes, but the association was stronger with L-ASPECTS (p<0.0001 and AUC=0.7 for L-ASPECTS; p=0.04 and AUC=0.59 for ASPECTS). Conclusion: Leukoaraiosis severity on pre-mechanical thrombectomy NCCT is associated with worse 90-day outcome in patients with AIS following endovascular recanalization, and is an independent risk factor for worse outcomes. A proposed L-ASPECTS score had stronger association with outcome than the traditional ASPECTS score.

Leukoaraiosis and acute ischemic stroke: 90-day clinical outcome following endovascular recanalization, with proposed “L-ASPECTS”

2020 ◽  
pp. neurintsurg-2020-015957 ◽  
Author(s):  
John Benson ◽  
Seyed Mohammad Seyedsaadat ◽  
Ian Mark ◽  
Deena M Nasr ◽  
Alejandro A Rabinstein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Primary Outcome Measure ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Endovascular Recanalization ◽  
Poor Outcomes

BackgroundTo assess if leukoaraiosis severity is associated with outcome in patients with acute ischemic stroke (AIS) following endovascular thrombectomy, and to propose a leukoaraiosis-related modification to the ASPECTS score.MethodsA retrospective review was completed of AIS patients that underwent mechanical thrombectomy for anterior circulation large vessel occlusion. The primary outcome measure was 90-day mRS. A proposed Leukoaraiosis-ASPECTS (“L-ASPECTS”) was calculated by subtracting from the traditional ASPECT based on leukoaraiosis severity (1 point subtracted if mild, 2 if moderate, 3 if severe). L-ASEPCTS score performance was validated using a consecutive cohort of 75 AIS LVO patients.Results174 patients were included in this retrospective analysis: average age: 68.0±9.1. 28 (16.1%) had no leukoaraiosis, 66 (37.9%) had mild, 62 (35.6%) had moderate, and 18 (10.3%) had severe. Leukoaraiosis severity was associated with worse 90-day mRS among all patients (P=0.0005). Both L-ASPECTS and ASPECTS were associated with poor outcomes, but the area under the curve (AUC) was higher with L-ASPECTS (P<0.0001 and AUC=0.7 for L-ASPECTS; P=0.04 and AUC=0.59 for ASPECTS). In the validation cohort, the AUC for L-ASPECTS was 0.79 while the AUC for ASPECTS was 0.70. Of patients that had successful reperfusion (mTICI 2b/3), the AUC for traditional ASPECTS in predicting good functional outcome was 0.80: AUC for L-ASPECTS was 0.89.ConclusionsLeukoaraiosis severity on pre-mechanical thrombectomy NCCT is associated with worse 90-day outcome in patients with AIS following endovascular recanalization, and is an independent risk factor for worse outcomes. A proposed L-ASPECTS score had stronger association with outcome than the traditional ASPECTS score.

Abstract TP49: Acute Intracranial Stenting With Mechanical Thrombectomy Shows No Difference in Discharge Outcomes Compared With Mechanical Thrombectomy Alone

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Wondwossen G Tekle ◽  
Laurie Preston ◽  
Adnan I Qureshi
Keyword(s):  
Length Of Stay ◽  
Mechanical Thrombectomy ◽  
Vessel Occlusion ◽  
Intracranial Stenting ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Discharge Outcomes ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Proven Method

Background: Mechanical thrombectomy (MT) is a proven method of treating patients with acute ischemic stroke (AIS) from a large vessel occlusion. However, there has been controversy regarding the safety and efficacy of incorporating acute intracranial stenting in addition to standard MT especially after the WEAVE trial results which showed a significant increase in stroke and hemorrhage in patients receiving wingspan stenting within 7 days of index ischemic event. We compared the outcomes of all AIS patients treated with acute intracranial stenting + MT versus MT alone. Methods: Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012-2019, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage (ICH), mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score (TICI) and modified Rankin Scale at discharge (mRS dc) were examined. The outcomes between patients receiving acute intracranial stenting + MT and patients that underwent MT alone were compared. Results: There were a total of 439 AIS patients who met criteria for the study (average age 70.38 ± 13.46 years; 45.6% were women). Analysis of 36 patients from the acute stenting + MT group (average age 66.72 ± 13.17 years; 30.6% were women), and 403 patients from the MT Alone group (average age 70.71 ± 13.45 years; 46.9% were women); see Table 1 for baseline characteristics and outcomes. Three patients (8.3%) in the acute stenting + MT group experienced ICH versus forty-four patients (10.9%) in the MT alone group (P=0.631); no significant increases were noted in length of stay (9.08 days vs 9.84 days; P=0.620) or good mRS scores at dc (P=0.636). Conclusion: Acute intracranial stenting in addition to MT was not associated with an increase in ICH rates, overall length of stay, or poor outcome upon discharge of patients. Prospective studies are recommended.

scholarly journals In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

2020 ◽  
Author(s):  
Juha-Pekka Pienimäki ◽  
Jyrki Ollikainen ◽  
Niko Sillanpää ◽  
Sara Protto
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ordinal Logistic Regression Analysis ◽  
Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

scholarly journals Can diffusion- and perfusion-weighted imaging alone accurately triage anterior circulation acute ischemic stroke patients to endovascular therapy?

2018 ◽  
Vol 10 (12) ◽  
pp. 1132-1136 ◽  
Author(s):  
Dylan N Wolman ◽  
Michael Iv ◽  
Max Wintermark ◽  
Gregory Zaharchuk ◽  
Michael P Marks ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Primary Outcome ◽  
Outcome Measure ◽  
Primary Outcome Measure ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Perfusion Weighted Imaging

Background and purposeAcute ischemic stroke (AIS) patients who benefit from endovascular treatment have a large vessel occlusion (LVO), small core infarction, and salvageable brain. We determined if diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) alone can correctly identify and localize anterior circulation LVO and accurately triage patients to endovascular thrombectomy (ET).Materials and methodsThis retrospective cohort study included patients undergoing MRI for the evaluation of AIS symptoms. DWI and PWI images alone were anonymized and scored for cerebral infarction, LVO presence and LVO location, DWI-PWI mismatch, and ET candidacy. Readers were blinded to clinical data. The primary outcome measure was accurate ET triage. Secondary outcomes were detection of LVO and LVO location.ResultsTwo hundred and nineteen patients were included. Seventy-three patients (33%) underwent endovascular AIS treatment. Readers correctly and concordantly triaged 70 of 73 patients (96%) to ET (κ=0.938; P=0.855) and correctly excluded 143 of 146 patients (98%; P=0.942). DWI and PWI alone had a 95.9% sensitivity and a 98.4% specificity for accurate endovascular triage. LVO were accurately localized to the ICA/M1 segment in 65 of 68 patients (96%; κ=0.922; P=0.817) and the M2 segment in 18 of 20 patients (90%; κ=0.830; P=0.529).ConclusionAIS patients with anterior circulation LVO are accurately identified using DWI and PWI alone, and LVO location may be correctly inferred from PWI. MRA omission may be considered to expedite AIS triage in hyperacute scenarios or may confidently supplant non-diagnostic or artifact-limited MRA.

Abstract P263: Do Different Sites of Vessel Occlusion Dictate the Need for Intubation Prior to Endovascular Treatment and Have an Effect on Outcome?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Raul G Nogueira ◽  
Laurie Preston ◽  
Adnan I Qureshi ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Independence ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
Baseline Characteristics ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Proven Method ◽  
Morbid Conditions

Introduction: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established. Methods: Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared. Results: Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions. Conclusion: Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.

Abstract MP35: Blood Pressure Reductions Before Arrival at a Thrombectomy-Capable Hospital Are Associated With Neurologic Worsening in Patients With Large-Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jessica Kobsa ◽  
Ayush Prasad ◽  
Alexandria Soto ◽  
Sreeja Kodali ◽  
Cindy Khanh Nguyen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Management Strategies ◽  
Vessel Occlusion ◽  
Time Points ◽  
Good Outcome ◽  
Primary Stroke Center ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Radiographic Data

Introduction: Decreases in blood pressure (BP) during thrombectomy are associated with infarct progression and worse outcomes. Many patients present first to a primary stroke center (PSC) and are later transferred to a comprehensive stroke center (CSC) to undergo thrombectomy. During this period, important BP variations might occur. We evaluated the association of BP reductions with neurological worsening and functional outcomes. Methods: We prospectively collected hemodynamic, clinical, and radiographic data on consecutive patients with LVO ischemic stroke who were transferred from a PSC for possible thrombectomy between 2018 and 2020. We assessed systolic BP (SBP) and mean arterial pressure (MAP) at five time points: earliest recorded, average pre-PSC, PSC admission, average PSC, and CSC admission. We measured neurologic worsening as a change in NIHSS (ΔNIHSS) from PSC to CSC >3 and functional outcome using the modified Rankin Scale (mRS) at discharge and 90 days. Relationships between variables of interest were evaluated using linear regression. Results: Of 91 patients (mean age 70±16 years, mean NIHSS 12) included, 13 (14%) experienced early neurologic deterioration (ΔNIHSS>3), and 34 (37%) achieved a good outcome at discharge (mRS<3). We found that patients with good outcome had significantly lower SBP at all five assessed time points compared to patients with poor outcome (Figure 1, p<0.05). Percent change in MAP from initial presentation to CSC arrival was independently associated with ΔNIHSS after adjusting for age, sex, and transfer time (p=0.03, β=0.27). Conclusions: Patients with poor outcomes have higher BP throughout the pre-CSC period, possibly reflecting an augmented hypertensive response. Reductions in SBP and MAP before arrival at the CSC are associated with neurologic worsening. These results suggest that BP management strategies in the pre-CSC period to avoid large reductions in BP may improve outcomes in patients affected by LVO stroke.

Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kavit Shah ◽  
Shashvat Desai ◽  
Benjamin Morrow ◽  
Pratit Patel ◽  
Habibullah Ziayee ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
To Receive ◽  
Rapid Transfer

Introduction: Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO). Methods: Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome. Results: Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO <=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO >120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital. Conclusion: Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.

Abstract 1122‐000091: Predictors of Symptomatic Hemorrhagic Transformation After Mechanical Thrombectomy in Acute Ischemic Stroke

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Anqi Luo ◽  
Agnelio Cardenas ◽  
Lee A Birnbaum
Keyword(s):  
Risk Factors ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Hemorrhagic Transformation ◽  
Current Standard ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Introduction : Mechanical thrombectomy (MT) has become the current standard of care for large vessel occlusion stroke but is associated with an increased risk of intracranial hemorrhage (ICH). Although several studies have investigated the risk factors, there is still limited, not well‐established data. This study aims to evaluate the risk factors of HT after MT. Methods : We retrospectively reviewed all MT patients who were treated at a single comprehensive stroke center from 12/2016 to 7/2019. Variables included initial NIHSS, blood glucose, initial systolic blood pressure, age, gender, IV tPA, time from door to recanalization, and TICI score. Outcome measures were HT on post‐procedure or 24‐hour post‐tPA head CT/MRI as well as modified Rankin scale (mRS) upon discharge. Results : Among 74 patients (68.8 ± 14 years, men 47.3%), 9 (12.2%) experienced hemorrhagic transformation after thrombectomy. Average admitting NIHSS was significantly higher in the HT group (22 vs 16.8, p = 0.041). TICI 3 after MT was protective for HT (OR 0.078, 95% CI 0.009‐0.663). IV tPA (OR 3.86, 95% CI 1.448‐10.326) was associated with good neurological outcome at discharge (mRS < = 2), but HT was not (OR 0.114, 95% CI 0.013‐0.964). Patients with mRS < = 2 upon discharge were younger (65.2±12 vs 71.9±15, p = 0.04) and had lower initial BG (124±45.8 vs 157±69.6, P = 0.02). Conclusions : TICI 3 score, decreased NIHSS, and lower BG were associated with less HT and better outcomes in our MT cohort. Admitting NIHSS > = 20 may be a reasonable threshold to predict HT after MT. Our findings are consistent with the TICI‐ASPECTS‐glucose (TAG) score to predict sICH; however, we used initial NIHSS as a surrogate for ASPECTS. Further studies may utilize additional quantitative measures such as CTP data to predict HT.

Abstract P562: The Safety Of Mechanical Thrombectomy In Nonagenarians In A Majority Hispanic Population

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nura Salhadar ◽  
WONDWOSSEN TEKLE ◽  
Amrou Sarraj ◽  
Ameer E Hassan
Keyword(s):  
Primary Outcome ◽  
Mechanical Thrombectomy ◽  
Statistical Significance ◽  
Hispanic Population ◽  
Vessel Occlusion ◽  
Border Communities ◽  
Baseline Characteristics ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Background and objective: Elderly patients were underrepresented in RCTs that proved the efficacy and safety of mechanical thrombectomy (MT) in acute ischemic strokes (AIS) due to large vessel occlusion (LVO). Additionally, the impact of race and socio-economics in AIS outcomes is well-reported. We sought to assess MT clinical outcomes in Hispanic Octogenarians and Nonagenarians that reside in underserved border communities. Methods: A retrospective cohort study from a prospectively collected comprehensive stroke center database was conducted. The primary outcome was discharge (mRS 0-2). Secondary outcomes were NIHSS improvement ≥4 points at discharge, sICH, mortality and length of stay (LOS). A two-tailed t-test assessed statistical significance between the two groups. Results: Of 202 included patients, 172 (85%) were octogenarians and 30 nonagenarians (17%). Nonagenarians had higher rates of females (80% vs 59%; p<0.05), similar rates of Hispanics (57% vs. 63%, p-xx) and a trend towards higher NIHS (20 vs. 17, P=0.09). Other baseline characteristics were similar (Table 1). Time last known well to arrival to MT center and to recanalization were longer in octogenarians, all other time metrics did not differ. Nonagenarians had numerically lower favorable outcomes at discharge (7% vs. 16%, p=0.11) as compared to octogenarians. Rates of clinical improvement on NIHSS were similar (27% vs. 23%, p=0.74). Mortality (23% vs. 28%, p=0.63) and sICH (7% vs 4%, p=0.46), octogenarians and nonagenarians, respectively. Octogenarians trended towards longer LOS (10 vs 6 days, p=0.05). Conclusions: Both groups had lower favorable good outcome rates than MT outcomes reported in RCTs. Nonagenarians had numerically lower favorable outcomes but mortality and sICH were similar. Further studies are warranted to further assess the impact of age and socioeconomics on MT outcomes.

scholarly journals Thrombectomy 6-24 hours after stroke in trial ineligible patients

2018 ◽  
Vol 10 (11) ◽  
pp. 1033-1037 ◽  
Author(s):  
Shashvat M Desai ◽  
Marcelo Rocha ◽  
Bradley J Molyneaux ◽  
Matthew Starr ◽  
Cynthia L Kenmuir ◽  
...  
Keyword(s):  
Time Window ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Off Label ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and purposeThe DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials.MethodsA retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6–24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes.ResultsApproximately 70% (n=142) of the 204 patients presenting 6–24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0–2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectivelyConclusionTrial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.

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