Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis

Saver, Jeffrey L.; Goyal, Mayank; Lugt, Aad van der; Menon, Bijoy K; Majoie, Charles B. L. M.; Dippel, Diederik W.J.; Campbell, Bruce; Nogueira, Raul G; Demchuk, Andrew M.; Tomasello, Alejandro; Cardona, Pere; Devlin, Thomas; Frei, Donald; Rochemont, Richard du Mesnil de; Berkhemer, Olvert A.; Jovin, Tudor G; Siddiqui, Adnan H.; Zwam, Wim H. van; Davis, Stephen M.; Castaño, Carlos; Sapkota, Biggya; Fransen, Puck S.S.; Molina, Carlos A.; Oostenbrugge, Robert J. van; Chamorro, Ángel; Lingsma, Hester F.; Silver, Frank L.; Donnan, Geoffrey A.; Shuaib, Ashfaq; Brown, Scott; Stouch, Bruce C.; Mitchell, Peter; Dávalos, Antoni; Roos, Yvo B.W.E.M.; Hill, Michael D.

doi:10.1001/jama.2016.13647

Cited by 1,785 publications

(1,410 citation statements)

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“…Mechanical thrombectomy (MT) is indicated for the treatment of large vessel occlusion (LVO) stroke(Goyal et al., 2016), and the time to administer mechanical thrombectomy is a very important factor for good clinical outcome (Saver et al., 2016). MT is offered only in comprehensive stroke centers (CSC), as an endovascular team is required for the procedure.…”

Section: Introductionmentioning

confidence: 99%

Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion

et al. 2018

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Background and PurposeMechanical thrombectomy (MT) is indicated for the treatment of large vessel occlusion (LVO) stroke. MT should be provided as quickly as possible; therefore, a test identifying suspected LVO in the prehospitalization stage is needed to ensure direct transport to a comprehensive stroke center (CSC). We assume that patients with clinically severe hemiparesis have a high probability of LVO stroke. We modified the FAST test into the FAST PLUS test: The first part is the FAST test and the second part evaluates the presence of severe arm or leg motor deficit. This prospective multicenter study evaluates the specificity and sensitivity of the FAST PLUS test in detecting LVO stroke.MethodsParamedics were trained through e‐learning to conduct the FAST PLUS test.All prehospital suspected stroke patients who were administered the FAST PLUS test were included. Demographics, National Institutes of Health Stroke Scale (NIHSS) score, brain computed tomography (CT), and CT angiography (CTA) were recorded. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operating curve (ROC) area for LVO were calculated.ResultsThe study included 435 patients. LVO were found in 124 patients (28%). Sensitivity was 93%, specificity was 47%, PPV was 41%, NPV was 94%, and ROC area for ICA/MCA occlusion was 0.65. Intracerebral hemorrhage (ICH) was identified in 48 patients (11%).ConclusionWe found that the FAST PLUS test had a high sensitivity for LVO stroke. Of the 435 patients, 41% were all directly transported to a CSC based on positive FAST PLUS test scores and were potential candidates for MT.

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Section: Introductionmentioning

confidence: 99%

Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion

et al. 2018

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“…The rate of functional independence was 64% with reperfusion at 3 hours and 46% with reperfusion at 8 hours. 26 As in our illustrative case, and in cases with proximal and distal tandem occlusions with patency of the carotid terminus and proximal intracranial segments on CTA, we prefer to perform a distal to proximal approach for revascularization. In this specific subset of patients, we believe that revascularization could be obtained faster from distal collaterals, and this might be associated with reduced time to recanalization and possibly a better outcome.…”

Section: Discussionmentioning

confidence: 94%

Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case

Mbabuike¹,

Gassie²,

Brown³

et al. 2017

FOC

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OBJECTIVE Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines. METHODS The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases. RESULTS A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively. CONCLUSIONS In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.

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“…Whereas in an analysis of the NINDS data the "line of no effect" was already reached after 2.5 h [2], later metaanalyses including studies with broader inclusion criteria suggested time windows of 4.5 h in 2010 [3] and of 5.1 h in 2014 [4]. A similar effect can be observed for thrombectomy that seemed to be efficacious until 6.3 h first [5] and later until 7.3 h [6]. It is important to understand that the decreasing therapy benefit (for the patient population within the trials) is inversely related to the average increase in infarct volume (and thus shrinking amount of tissue and function that can be saved by the therapy).…”

mentioning

confidence: 87%

“…If significant, this data would suggest that actually delaying imaging would be beneficial (sic) but then we need to hurry up once imaging is done. Similarly, in the patient-level meta-analysis of the recent thrombectomy trials [6], there was no interaction of the time from symptom onset to the emergency room and therapy effect. In contrast, there was an absolute poor outcome (mRS 3-6) risk increase for every hour delay between emergency room and reperfusion of 13.7% (8.6 to 18.2).…”

mentioning

confidence: 90%

The Time–Reset Effect

Fiehler

2017

Clin Neuroradiol

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Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis

Cited by 1,785 publications

References 27 publications

Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion

Prehospital stroke scale (FAST PLUS Test) predicts patients with intracranial large vessel occlusion

Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case

The Time–Reset Effect

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