Comparing extended versus standard time window for thrombectomy: caseload, patient characteristics, treatment rates and outcomes—a prospective single-centre study

Abstract

Purpose New guidelines recommend thrombectomy up to 24 h in selected patients; however, the workload and benefit of extending time window are not known. We conducted a prospective single-centre study to determine the caseload, imaging and interventional need of extended time window. Methods All consecutive ischemic stroke patients within 24 h from onset in an 11-month period were included. Thrombectomy eligibility in the 0–6 h time window was based on current guidelines; in the 6–24 h time window, it was based on a combination of DEFUSE 3 and DAWN study criteria using MRI to identify target mismatch. Clinical outcome in treated patients was assessed at 3 months. Results Within 24 h of onset, 437 patients were admitted. In the 0–6 h time window, 238 patients (54.5%) arrived of whom 221 (92.9%) underwent CTA or MRA, 82 (34.5%) had large vessel occlusion (LVO), 30 (12.6%) had thrombectomy and 11 (36.6%) became independent (mRS ≤ 2). In the extended 6–24 h time window, 199 patients (45.5%) arrived of whom 127 (63.8%) underwent CTA or MRA, 44 (22.1%) had LVO, 8 (4%) had thrombectomy and 4 (50%) became independent. Conclusion Extending the time window from 6 to 24 h results in a 26.7% increase in patients receiving thrombectomy and a 36.4% increase of independent clinical outcome in treated patients at the price of a significantly increased burden of clinical and imaging screening due to the similar caseload but a smaller proportion of treatment eligible patients in the extended as compared with the standard time window.

What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review

“…Both RCTs demonstrated the superiority of MT to standard care in eligible patients. The findings translated well into daily practice: large retrospective studies found MT to be effective and safe even with the application of less strict selection criteria [ 44 , 45 , 46 , 47 ].…”

Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

“…Since extending the therapeutic window from 6 to 24 h may result to an increase up to 27% in patients receiving EVT, the importance of recent late time window RCTs becomes evident. 72 It should be noted that the HERMES meta-analysis showed that benefit of EVT using standard neuroimaging remains statistically significant up to 7 h and 18 min from LSW. This temporal cut-off has been adopted by the 2019 joint ESO and European Society for Minimally Invasive Neurological Therapy (ESMINT) EVT Guidelines.…”

Prognostic estimation for acute ischemic stroke patients undergoing mechanical thrombectomy within an extended therapeutic window using an interpretable machine learning model

“…Mechanical Thrombectomy (MT) has established its efficacy as a primary treatment for acute ischemic stroke with large vessel occlusion (AIS-LVO), providing substantial benefits, especially within the initial 6-h therapeutic window (Wahlgren et al, 2016;Bhan et al, 2020). However, a significant proportion of AIS-LVO patients, estimated to be approximately 30-40%, present to care facilities beyond this traditional window, specifically between 6 and 24 h from symptom onset (Jadhav et al, 2018;Gunda et al, 2021). While the DEFUSE 3 (Endovascular therapy following imaging evaluation for ischemic stroke 3) and DAWN (Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo) trials have indicated the potential benefits of MT in this extended time window, they also highlighted the variability in outcomes (Jabal et al, 2023;Zhan et al, 2023), with beneficial functional outcomes at 90 days observed in roughly 45 and 49% of patients, respectively (Albers et al, 2018;Nogueira et al, 2018).…”