Eligibility for Endovascular Trial Enrollment in the 6- to 24-Hour Time Window

Jadhav, Ashutosh P.; Desai, Shashvat M; Kenmuir, Cynthia L.; Rocha, Marcelo; Starr, Matthew; Molyneaux, Bradley J.; Gross, Bradley A.; Jankowitz, Brian T.; Jovin, Tudor G

doi:10.1161/strokeaha.117.020273

Cited by 115 publications

(79 citation statements)

References 5 publications

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“…Time is still important and delays in treatment should be avoided. A significant number of patients presenting in the extended window do not have favorable imaging profile 35 . Moreover, those with favorable profile (slow progressors), become ineligible for treatment if not recanalized immediately after onset and develop extensive infarction leading to poor outcomes 36,37 .…”

Section: Discussionmentioning

confidence: 99%

Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes

Bhan

Koehler²,

Elisevich

et al. 2020

Journal of Neuroimaging

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BACKGROUND AND PURPOSE: Recent trials have shown benefit of thrombectomy in patients selected by penumbral imaging in the late (>6 hours) window. However, the role penumbral imaging is not clear in the early (0-6 hours) window. We sought to evaluate if time to treatment modifies the effect of endovascular reperfusion in stroke patients with evidence of salvageable tissue on CT perfusion (CTP). METHODS: We retrospectively analyzed consecutive patients who underwent thrombectomy in a single center. Demographics, comorbidities, National Institute of Health Stroke Scale (NIHSS), rtPA administration, ASPECTS, core infarct volume, onset to skin puncture time, recanalization (mTICI IIb/III), final infarct volume were compared between patients with good and poor 90-day outcomes (mRS 0-2 vs. 3-6). Multivariable logistic regression analyses were used to identify independent predictors of a good (mRS 0-2) 90-day outcome. RESULTS: A total of 235 patients were studied, out of which 52.3% were female. Univariate analysis showed that the groups (early vs. late) were balanced for age (P = .23), NIHSS (P = .63), vessel occlusion location (P = .78), initial core infarct volume (P = .15), and recanalization (mTICI IIb/III) rates (P = .22). Favorable outcome (mRS 0-2) at 90 days (P = .30) were similar. There was a significant difference in final infarct volume (P = .04). Shift analysis did not reveal any significant difference in 90-day outcome (P = .14). After adjustment; age (P < .001), NIHSS (P = .01), recanalization (P = .008), and final infarct volume (P < .001) were predictive of favorable outcome. CONCLUSIONS: Penumbral imaging-based selection of patients for thrombectomy is effective regardless of onset time and yields similar functional outcomes in early and late window patients.

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Section: Discussionmentioning

confidence: 99%

Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes

Bhan

Koehler²,

Elisevich

et al. 2020

Journal of Neuroimaging

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“…These two high quality studies together led to the AHA guidelines designating mechanical thrombectomy up to 16 hours from onset for carefully selected patients as a class 1A recommendation 10. A single center study estimated that about 1.7-2.5% of all acute stroke admissions would be eligible for thrombectomy after six hours from LKW on the basis of DAWN and/or DEFUSE 3 criteria66 (fig 2).…”

Section: Mechanical Thrombectomy For Acute Ischemic Strokementioning

confidence: 99%

Management of acute ischemic stroke

Phipps

Cronin

2020

BMJ

439

315

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Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.

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“…At the time of this study, it was estimated that 56% of the United States' population had access to endovascular-capable hospitals within 60 min by ground transportation 10. By some estimates, as many as 20 000 of the 650 000 AIS patients in the United States annually may be eligible for ET based on the criteria from the DAWN and DEFUSE-3 trials whose results form the basis for the 2018 American Heart Association/American Stroke Association (AHA/ASA) extended window guidelines 11–13. This number may be even greater as we attempt to identify patients not included in the original randomized trials, including those with more distal LVO, who may benefit from ET 14.…”

Section: Introductionmentioning

confidence: 99%

National trends in endovascular therapy for acute ischemic stroke: utilization and outcomes

Stein

Tuhrim

Fifi

et al. 2019

J NeuroIntervent Surg

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ObjectiveFollowing widespread acceptance of endovascular therapy (ET) for large vessel occlusion stroke in 2015, we assessed nationwide utilization of revascularization for acute ischemic stroke (AIS).MethodsWe utilized the 2013–2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database. We identified AIS admissions, treatment with intravenous thrombolysis (IVT), ET, and vascular risk factors using International Classification of Disease Clinical Modification codes. Main predictor of outcome was the time period of index admission (‘pre-endovascular era (pre-EA)’ January 2013–January 2015 and ‘endovascular era (EA)’ February 2015– December 2016). We calculated the proportion of AIS admissions in which, first, VT and second, ET was performed. Among patients treated with ET, we examined the association between era and discharge disposition, in-hospital mortality during index admission, and 30-day readmission.ResultsThere were 925 363 index AIS admissions before the EA and 857 347 during. A higher proportion of AIS patients received IVT (8.4% vs 7.8%) and ET (2.6% vs 1.3%) in the EA. Although length of stay (LOS) was shorter in the EA (5.70 vs 6.80 days), total charges were greater ($56 691 vs $53 878), and admissions were more often to a metropolitan hospital (65.2% vs 57.2%). Among those treated with ET, a smaller proportion received IVT (29.7% vs 44.9%), LOS was substantively shorter (9.75 vs 12.76 days), and patients had a lower odds of discharge home.ConclusionsThe utilization of ET has doubled in the EA but ET remains underutilized. ET is predominantly provided at metropolitan teaching hospitals and associated with higher charges despite shorter LOS and unchanged in-hospital mortality.

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Eligibility for Endovascular Trial Enrollment in the 6- to 24-Hour Time Window

Cited by 115 publications

References 5 publications

Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes

Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes

Management of acute ischemic stroke

National trends in endovascular therapy for acute ischemic stroke: utilization and outcomes

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