Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients: A Subgroup Analysis From the BEST Prospective Cohort Study

Siegler, James E.; Messé, Steven R.; Sucharew, Heidi; Kasner, Scott E.; Mehta, Tapan; Arora, Niraj; Starosciak, Amy; Rosa, Felipe De Los Rios La; Barnhill, Natasha R; Mistry, Akshitkumar M.; Patel, Kishan; Assad, Salman; Tarboosh, Amjad; Dakay, Katarina; Salwi, Sanjana; Wagner, Jeff; Bennett, Alicia; Jagadeesan, Bharathi; Streib, Christopher; Weber, Sydney; Chitale, Rohan; Volpi, John; Mayer, Stephan A.; Yaghi, Shadi; Jayaraman, Mahesh; Khatri, Pooja; Mistry, Eva

doi:10.1093/neuros/nyz485

Cited by 21 publications

(20 citation statements)

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“…This confirms observations made in patients who present in the early window, and corroborates recently published findings in one cohort treated in the extended window . Whether selected patients from this cohort still derive an overall benefit from thrombectomy (versus medical management alone) deserves further investigation and is being reported separately . Our findings emphasize the critical importance of reviewing the noncontrast CT before selecting patients for thrombectomy, even in the presence of favorable perfusion imaging profiles.…”

Section: Discussionsupporting

confidence: 90%

Noncontrast CT versus Perfusion‐Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study

Siegler

Messé

Sucharew

et al. 2019

Journal of Neuroimaging

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BACKGROUND AND PURPOSE The 2018 AHA guidelines recommend perfusion imaging to select patients with acute large vessel occlusion (LVO) for thrombectomy in the extended window. However, the relationship between noncontrast CT and CT perfusion imaging has not been sufficiently characterized >6 hours after last known normal (LKN). METHODS From a multicenter prospective cohort of consecutive adults who underwent thrombectomy for anterior LVO 0–24 hours after LKN, we correlated baseline core volume (rCBF < 30%) and the Alberta Stroke Program Early CT Scale (ASPECTS) score. We compared perfusion findings between patients with an unfavorable ASPECTS (<6) against those with a favorable ASPECTS (≥6), and assessed findings over time. RESULTS Of 485 enrolled patients, 177 met inclusion criteria (median age: 69 years, interquartile range [IQR: 57‐81], 49% female, median ASPECTS 8 [IQR: 6‐9], median core 10 cc [IQR: 0‐30]). ASPECTS and core volume moderately correlated (r = −.37). A 0 cc core was observed in 54 (31%) patients, 70% of whom had ASPECTS <10. Of the 28 patients with ASPECTS <6, 3 (11%) had a 0 cc core. After adjustment for age and stroke severity, there was a lower ASPECTS for every 1 hour delay from LKN (cOR: 0.95, 95% confidence of interval [CI]: 0.91‐1.00, P = .04). There was no difference in core (P = .51) or penumbra volumes (P = .87) across patients over time. CONCLUSIONS In this multicenter prospective cohort of patients who underwent thrombectomy, one‐third of patients had normal CTP core volumes despite nearly three quarters of patients showing ischemic changes on CT. This finding emphasizes the need to carefully assess both noncontrast and perfusion imaging when considering thrombectomy eligibility.

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Section: Discussionsupporting

confidence: 90%

Noncontrast CT versus Perfusion‐Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study

Siegler

Messé

Sucharew

et al. 2019

Journal of Neuroimaging

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“…This is in line with a recent single-center analysis by Salam et al (n = 166) where good functional outcome occurred in 24% [17]. The BEST cohort [9], another real-life study, also found worse clinical results of trial-eligible patients when compared to the randomized studies, but these were more favorable than in our cohort (mRS 0-2 = 30%, 14/47); however, the estimated infarct core volumes in BEST were very small (6 ml [0-20]) [9]. A very high proportion of patients with a good clinical outcome (67%) was found in a Swiss study including 52 ET patients [7] but the majority of patients (71.1%) in this study had M2 occlusions, which are in general more often associated with a good clinical outcome [18].…”

Section: Prevalence and Outcomesupporting

confidence: 90%

“…The 25 participating centers reflect both primary and comprehensive stroke centers (12 university hospitals and 13 municipal hospitals). A detailed description of the GSR study design, obtained parameters, and main outcome data was recently published [9,10].…”

Section: Study Populationmentioning

confidence: 99%

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Late Thrombectomy in Clinical Practice

et al. 2021

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Background and Purpose To provide real-world data on outcome and procedural factors of late thrombectomy patients. Methods We retrospectively analyzed patients from the multicenter German Stroke Registry. The primary endpoint was clinical outcome on the modified Rankin scale (mRS) at 3 months. Trial-eligible patients and the subgroups were compared to the ineligible group. Secondary analyses included multivariate logistic regression to identify predictors of good outcome (mRS ≤ 2). Results Of 1917 patients who underwent thrombectomy, 208 (11%) were treated within a time window ≥ 6–24 h and met the baseline trial criteria. Of these, 27 patients (13%) were eligible for DAWN and 39 (19%) for DEFUSE3 and 156 patients were not eligible for DAWN or DEFUSE3 (75%), mainly because there was no perfusion imaging (62%; n = 129). Good outcome was not significantly higher in trial-ineligible (27%) than in trial-eligible (20%) patients (p = 0.343). Patients with large trial-ineligible CT perfusion imaging (CTP) lesions had significantly more hemorrhagic complications (33%) as well as unfavorable outcomes. Conclusion In clinical practice, the high number of patients with a good clinical outcome after endovascular therapy ≥ 6–24 h as in DAWN/DEFUSE3 could not be achieved. Similar outcomes are seen in patients selected for EVT ≥ 6 h based on factors other than CTP. Patients triaged without CTP showed trends for shorter arrival to reperfusion times and higher rates of independence.

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“…In 2018, the DAWN and DEFUSE-3 trials demonstrated that MT was successfully applicable up to 24 h after stroke onset (16)(17)(18). Further trials investigated borderline LVO patients, such as large ischemic cores or distal occlusions (19,20). The number of MT procedures is expected to increase further.…”

Section: Discussion Of Results For Clinical Practicementioning

confidence: 99%

Only a Minority of Thrombectomy Candidates Are Admitted During Night Shift: A Rationale for Diurnal Stroke Care Planning

et al. 2020

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Background: Widespread quick access to mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is one of the main challenges in stroke care. It is unclear if newly established MT units are required 24 h/7 d. We explored the diurnal admission rate of patients with AIS potentially eligible for MT to provide a basis for discussion of daytime-adapted stroke care concepts. Methods: Data collected from the Baden-Württemberg Stroke Registry in Germany were assessed (2008-2012). We analyzed the admission rate of patients with AIS stratified by the National Institutes of Health Stroke Scale (NIHSS) score at admission in 3-h intervals. An NIHSS score ≥10 was considered a predictor of large vessel occlusion. The average annual admission number of patients with severe AIS were stratified by stroke service level and calculated for a three-shift model and working/non-working hours. Results: Of 91,864, 22,527 (21%) presented with an NIHSS score ≥10. The average admission rates per year for a hospital without Stroke Unit (SU), with a local SU, with a regional SU and a stroke center were 8, 52, 90 and 178, respectively. Approximately 61% were admitted during working hours, 54% in the early shift, 36% in the late shift and 10% in the night shift. Conclusions: A two-shift model, excluding the night shift, would cover 90% of the patients with severe AIS. A model with coverage during working hours would miss ∼40% of the patients with severe AIS. To achieve a quick and area-wide MT, it seems preferable for newly implemented MT-units to offer MT in a two-shift model at a minimum.

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Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients: A Subgroup Analysis From the BEST Prospective Cohort Study

Cited by 21 publications

References 17 publications

Noncontrast CT versus Perfusion‐Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study

Noncontrast CT versus Perfusion‐Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study

Late Thrombectomy in Clinical Practice

Only a Minority of Thrombectomy Candidates Are Admitted During Night Shift: A Rationale for Diurnal Stroke Care Planning

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