Endovascular stroke treatment after 6‐24 hours only needs non‐contrast CT

Abstract

If more than 6 hours have elapsed since the known onset of stroke symptoms, current guidelines for patients set forth by the American Heart Association (AHA) restrict class-IA recommendation to selected patients who have large vessel occlusion (LVO) in the anterior circulation and those cases where images and other eligibility criteria from the DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo) and DEFUSE-3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) randomized control trials (RCTs) are strictly applied. 1-3 Ischaemic stroke is a dynamic condition in which the rate and extent of the stroke depend on multiple factors not only correlated

Acute stroke imaging selection for mechanical thrombectomy in the extended time window: is it time to go back to basics? A review of current evidence

“…One out of 18 studies prospectively recruited patients 47. The majority of the remaining studies (n=13) conducted post-hoc analyses of prospective trial data or endovascular therapy registries, that is, patient and imaging characteristics were retrospectively reviewed according to different predefined triage models and reported along with efficacy and safety outcomes 48–59.…”

“…Study populations of all studies comprised patients who had an acute ischaemic stroke with a large vessel occlusion (internal carotid artery, middle cerebral arteryM1, middle cerebral artery M2; one study also involved posterior territory occlusions48) which had presented 6–24 hours after onset of stroke symptoms or last known well. Studies providing group comparisons adhered to either of two principle study designs: (1) patients meeting the criteria of a basic imaging paradigm presenting 6–24 hours after stroke onset (basic LATE -group) were compared with patients routinely selected for endovascular therapy without the use of advanced imaging within 6 hours of stroke onset (basic EARLY -group) according to guidelines (n=5),47 49 52 60 62 or (2) within 6–24 hours after stroke onset, patients who fulfilled basic imaging criteria (late BASIC -group) were compared with patients meeting perfusion imaging criteria (late CTP -group) that matched or closely referred to the DAWN/DEFUSE3 selection criteria (n=10) 48 50 53–60 63. Seven studies additionally reported outcome data of patients not treated with endovascular therapy 47 48 51 53 55 58 64…”

“…As per our review inclusion criteria, all studies reported as primary outcome the rates of functional independence (mRS 0–2) at 90 days. Rates of sICH were reported in 12 studies47 49–53 56 59–63 and the 90 day mortality rate in 9 studies 47 50 55–57 59 61 63 64…”

“…Among the seven studies that provided outcome comparisons of patients treated with endovascular therapy versus patients treated conservatively (no endovascular therapy), reported outcomes in patients meeting the basic selection paradigm criteria (basic LATE -groups and late BASIC -groups) invariably favoured endovascular therapy performance 47 48 51 53 55 58 64. Besides, Albers et al found higher treatment benefits of endovascular therapy compared with conservative treatment in patients with a clinical core mismatch profile (OR 3.5; 95% CI 2.07 to 5.91, p<0.001) or a target perfusion mismatch profile (OR 2.9; 95% CI 1.88 to 4.47, p<0.001) than in patients selected without CTP/MRI (OR 1.68; 95% CI 0.87 to 3.22, p=0.1194) 64.…”

Comparison between collateral status and DEFUSE 3 or DAWN criteria in patient selection for endovascular thrombectomy within 6−24 hours after stroke: a protocol for meta-analysis

“…5 6 Moreover, patients with LVO in the extended time window can potentially benefit from EVT selected by simpler imaging triage. [7][8][9][10][11] Collateral vasculature status is important to compensate blood flow to the ischaemic area when the principal supplying arteries are occluded. 12 Good collaterals are related to limited ischaemic core and favourable clinical outcomes.…”