Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct

Nogueira, Raul G; Jadhav, Ashutosh P.; Haussen, Diogo C; Bonafé, Alain; Budzik, Ronald F; Bhuva, Parita; Yavagal, Dileep R.; Ribó, Marc; Cognard, Christophe; Hanel, Ricardó A.; Sila, Cathy A.; Hassan, Ameer E.; Millán, Mònica; Levy, Elad I.; Mitchell, Peter; Chen, Michael; English, Joey; Shah, Qaisar; Silver, Frank L.; Pereira, Vítor Mendes; Mehta, Brijesh; Baxter, Blaise; Abraham, Michael; Cardona, Pedro; Veznedaroglu, Erol; Hellinger, Frank R; Feng, Lei; Kirmani, Jawad F.; Lopes, Demetrius K.; Jankowitz, Brian T.; Frankel, Michael; Costalat, Vincent; Vora, Nirav; Yoo, Albert J.; Malik, Amer; Furlan, Anthony J.; Rubiera, Marta; Aghaebrahim, Amin; Olivot, Jean‐Marc; Tekle, Wondwossen G; Shields, Ryan; Graves, Todd L.; Lewis, Roger J.; Smith, Wade S.; Liebeskind, David S; Saver, Jeffrey L.; Jovin, Tudor G

doi:10.1056/nejmoa1706442

Cited by 4,409 publications

(3,522 citation statements)

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“…Based on these trial results, revised American Heart Association guidelines support the use of ET in patients presenting within 6 h of symptom onset, Alberta Stroke Program Early CT Score (CT ASPECTS) ≥6 and initial NIHSS ≥6, regardless of intravenous thrombolysis [6]. Recently, ET performed between 6 and 24 h from presumed symptom onset in LVOS patients with clinical-radiographic mismatch was found to be immensely beneficial [7]. These trials have also highlighted (1) the high recanalization rates with newer generation stent-retriever devices, (2) an urgent need for developing strategies that minimize treatment delays, and (3) need for universally applicable and validated tools for optimizing patient selection for ET that combine commonly available clinical and radiographic data [8, 9].…”

Section: Introductionmentioning

confidence: 99%

A Review of Pre-Intervention Prognostic Scores for Early Prognostication and Patient Selection in Endovascular Management of Large Vessel Occlusion Stroke

Raza

Rangaraju²

2018

Intervent Neurol

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Background: Endovascular therapy (ET) has emerged as a highly effective treatment for acute large vessel occlusion stroke (LVOS). Tools that facilitate optimal patient selection of patients for ET are needed in order to maximize therapeutic benefit in a cost-effective manner. Several pre-intervention prognostic scores for prediction of outcomes in LVOS patients and patient selection for ET have been developed and validated, but their clinical use has been limited. Here, we review existing pre-intervention prognostic scores, compare their prognostic accuracies and levels of validation and identify gaps in current knowledge. Summary: We have reviewed published literature pertinent to development, validation, and implementation of pre-intervention prognostic scores for LVOS. Using receiver operating characteristic curve analysis, the prognostic accuracies of validated pre-interventional scores (Pittsburgh Response to Endovascular therapy [PRE], Totaled Health Risks in Vascular Events [THRIVE], Houston Intra-Arterial Therapy-2 (HIAT-2), Stroke Prognostication using Age and NIHSS [SPAN-100]) were compared in published work. Pre-intervention scores predicted functional out comes at 3 months with moderate prognostic accuracies (area under the receiver operator characteristic curve range 0.68–0.73). Using successful reperfusion (mTICI 2B/3) as the therapeutic objective of ET and 3-month modified Rankin Score 0–2 as good clinical outcome, patients most likely to clinically benefit from endovascular reperfusion can be identified using the PRE and HIAT-2 scores. Scores that incorporate collateral imaging or perfusion-based estimation of core and penumbra have not been published. Existing scores are predominantly limited to anterior circulation LVOS, and implementation studies of pre-interventional scores are lacking. Key Messages: Pre-intervention prognostic scores can serve as useful adjuncts for patient selection in ET for acute LVOS. Pre-intervention scores including HIAT-2, THRIVE, SPAN-100, and PRE have comparable moderate prognostic accuracies for good 3-month outcomes and can identify patients who derive maximal benefit from successful reperfusion. Improvements in prognostic accuracy may be achieved by incorporating variables such as collateral status and perfusion imaging data. Implementation and impact studies using pre-intervention scores are needed to guide clinical application.

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Section: Introductionmentioning

confidence: 99%

A Review of Pre-Intervention Prognostic Scores for Early Prognostication and Patient Selection in Endovascular Management of Large Vessel Occlusion Stroke

Raza

Rangaraju²

2018

Intervent Neurol

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“…If there is moderate to good collateral filling and a favorable Alberta Stroke Program Early CT Score (ASPECTS), with a lower limit ranging from 5 to 7, EVT can be considered up to 12 h after symptom onset [2]. A recent trial has even shown that patients can be selected for EVT up to 24 h when using MR DWI or CT-perfusion (CTP) [3, 4]. …”

Section: Introductionmentioning

confidence: 99%

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

et al. 2018

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Background: Current guidelines for the treatment of acute ischemic stroke are mainly based on the time between symptom onset and initiation of treatment. This time is unknown in patients with wake-up stroke (WUS). We investigated clinical and multimodality CT imaging characteristics on admission in patients with WUS and in patients with a stroke with a known onset time. Methods: All patients were selected from a large prospective cohort study (Dutch acute stroke study). WUS patients last seen well > 4.5 and ≤4.5 h were separately compared to patients with a known onset time ≤4.5 h. In addition, WUS patients with a proximal occlusion of the anterior circulation last seen well > 6 and ≤6 h were separately compared to patients with a known onset time ≤6 h and a proximal occlusion. National Institute of Health Stroke Score, age, gender, history of atrial fibrillation, non-contrast CT (NCCT) Alberta Stroke Program Early CT Score (ASPECTS), CT-perfusion abnormalities, proximal occlusions, and collateral filling on CT angiography were compared between groups using the Mann-Whitney U test and Fisher’s exact test. Results: WUS occurred in 149/1,393 (10.7%) patients. Admission clinical and imaging characteristics of WUS patients last seen well > 4.5 h (n = 81) were not different from WUS patients last seen well ≤4.5 h (n = 68). Although WUS patients last seen well > 4.5 h had a significantly lower NCCT ASPECTS than patients with a known time of stroke symptom onset of ≤4.5 h (n = 1,026), 85.2% had an NCCT ASPECTS > 7 and 75% had a combination of favorable ASPECTS > 7 and good collateral filling. There were no statistically significant differences between the admission clinical and imaging characteristics of WUS patients with proximal occlusions last seen well > 6 h (n = 23), last seen well ≤6 h (n = 40), and patients with a known time to stroke symptom onset ≤6 h (n = 399). Of all WUS patients with proximal occlusions last seen well > 6 h, only 4.3% had severe ischemia (ASPECTS < 5), 13 (56.5%) had ASPECTS > 7 and good collateral filling. Conclusions: There are only minor differences between clinical and imaging characteristics of WUS patients and patients who arrive in the hospital within the time criteria for intravenous or endovascular treatment. Therefore, CT imaging may help to identify WUS patients who would benefit from treatment and rule out those patients with severe ischemia and poor collaterals.

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“…The DAWN trial showed an absolute difference of 35% for mRS 0-2 between the thrombectomy and control arms [3].…”

mentioning

confidence: 99%

“…The DAWN trial showed an absolute difference of 35% for mRS 0-2 between the thrombectomy and control arms [3].These massive effect sizes are very uncommon in any medical field. How did these treatment effects occur?…”

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confidence: 99%

Future trials on endovascular stroke treatment: the not-so-easy-to-pluck fruits

2017

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The EXTEND-IA trial showed a positive result in 71 patients (31% absolute effect size for mRS 0-2) [1].Data from the HERMES collaboration showed an NNT of 2.5 for a one point improvement in mRS in patients undergoing endovascular thrombectomy [2]. The DAWN trial showed an absolute difference of 35% for mRS 0-2 between the thrombectomy and control arms [3].These massive effect sizes are very uncommon in any medical field. How did these treatment effects occur? It is likely a combination of factors. First, we did not really expect IMS3 [4] that studied evolving endovascular stroke treatment techniques to show a negative result. It was a neutral study due to a combination of factors. Cherry picking (taking younger, earlier, healthier patients outside of the trial direct to endovascular thrombectomy) may have been a factor. Other factors commonly associated with IMS-3 that contributed to the negative results are as follows: absence of vascular imaging to definitively document the presence of LVO; lack of additional imaging markers such as collaterals or perfusion imaging to exclude patients with poor collaterals or a very large ischemic core; not using modern thrombectomy devices such as stent retrievers, an equal reperfusion rate in both treatment arms; and finally, insufficient focus on efficiency and workflow of the thrombectomy procedure. The results of IMS3 as well as SYNTHESIS Expansion [5] and MR RESCUE [6]) galvanized the stroke community into action, and many trials were then designed and successfully executed. These trials were for the most part designed to overcome the limitations of IMS3 as described above and furthermore, knowingly or unknowingly, selected inclusion/ exclusion criteria so as to conclusively demonstrate a large benefit of endovascular treatment. After the first group of trials, a second group of trials led by DAWN and DEFUSE-3 were conducted to show benefit in a highly focused group of patients (selected by imaging) beyond 6 h from stroke onset. Once again, the effect size of treatment was staggering.With the success of all these trials (MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, REVASCAT, THRACE, DAWN [1, 7-11]), there is the obvious question: are there other sub-populations of patients who would benefit from endovascular thrombectomy that were not sufficiently included in the prior trials? If so, should we use the success and momentum from the successful trials to show definitive proof for these sub-populations as well?

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Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct

Cited by 4,409 publications

References 25 publications

A Review of Pre-Intervention Prognostic Scores for Early Prognostication and Patient Selection in Endovascular Management of Large Vessel Occlusion Stroke

A Review of Pre-Intervention Prognostic Scores for Early Prognostication and Patient Selection in Endovascular Management of Large Vessel Occlusion Stroke

Wake-Up Stroke versus Stroke with Known Onset Time: Clinical and Multimodality CT Imaging Characteristics

Future trials on endovascular stroke treatment: the not-so-easy-to-pluck fruits

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