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Endovascular Thrombectomy Versus Best Medical Management Beyond 24 Hours From Last Known Well in Acute Ischemic Stroke Due to Large Vessel Occlusion

Dhillon, Permesh Singh; Butt, Waleed; Jovin, Tudor G; Podlasek, Anna; McConachie, Norman; Lenthall, Robert; Nair, Sujit; Malik, Luqman; Krishnan, Kailash; Dineen, Robert A.; England, Timothy J.

Endovascular Thrombectomy Versus Best Medical Management Beyond 24 Hours From Last Known Well in Acute Ischemic Stroke Due to Large Vessel Occlusion Thumbnail


Authors

Permesh Singh Dhillon

Waleed Butt

Tudor G Jovin

Anna Podlasek

Norman McConachie

Robert Lenthall

Sujit Nair

Luqman Malik

Kailash Krishnan

ROBERT DINEEN rob.dineen@nottingham.ac.uk
Professor of Neuroradiology



Abstract

BACKGROUND
The safety and efficacy of endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to large vessel occlusion presenting beyond 24 hours from last known well (LKW) remains undetermined.

METHODS
In this single center study, we identified patients with large vessel occlusion who were eligible for EVT based on noncontrast computed tomography (CT)/CT angiography (without CT perfusion or magnetic resonance imaging) using an Alberta Stroke Program Early CT Score of ≥5, National Institutes of Health Stroke Scale of ≥6, and presenting beyond 24 hours from LKW, between January 2018 and March 2022. During the study period, EVT service limitations meant patients eligible for EVT presenting outside service hours, routinely received best medical management (BMM). Functional and safety outcomes were compared between patients receiving EVT or BMM following multivariable adjustment for age, baseline stroke severity, Alberta Stroke Program Early CT Score, time from LKW, IV thrombolysis, and clot location.

RESULTS
Among 35 patients presenting beyond 24 hours from LKW and eligible for EVT, 19 (54%) were treated with EVT and 16 (46%) with BMM. Alberta Stroke Program Early CT Score were similar across both groups (EVT: 7 [6.75–8] versus BMM: 7 [6–8]), but not the baseline National Institutes of Health Stroke Scale (EVT: 17 [11–19.5] versus BMM: 20 [9.75–26]). No significant difference was observed between the EVT and BMM groups in the symptomatic intracranial hemorrhage (5.3% versus 0%; P=0.28) or mortality (26.3% versus 37.5%; P=0.42) rates, respectively. The modified Rankin scale at 90 days (adjusted common odds ratio [OR], 1.94; [95% CI 0.42–8.87]; P=0.39) and functional independence rate, although numerically higher in the EVT group compared with the BMM group (modified Rankin scale≤2; 36.9% versus 18.8%; adjusted OR, 4.34; [95% CI 0.34–54.83]; P=0.25), were not significantly different. 94.7% of patients treated with EVT achieved successful reperfusion (modified thrombolysis in cerebral infarction 2b–3).

CONCLUSION
In routine clinical practice, EVT beyond 24 hours from LKW appears safe and feasible, when performed in patients with acute ischemic stroke who were deemed eligible for EVT by noncontrast CT /CT angiography alone. A large collaborative randomized trial assessing the efficacy of EVT beyond 24 hours is warranted. Our findings provide a basis for the sample size estimate for an adequately powered trial.

Citation

Dhillon, P. S., Butt, W., Jovin, T. G., Podlasek, A., McConachie, N., Lenthall, R., …England, T. J. (2023). Endovascular Thrombectomy Versus Best Medical Management Beyond 24 Hours From Last Known Well in Acute Ischemic Stroke Due to Large Vessel Occlusion. Stroke: Vascular and Interventional Neurology, 3(5), Article e000790. https://doi.org/10.1161/svin.122.000790

Journal Article Type Article
Acceptance Date Feb 15, 2023
Online Publication Date Apr 28, 2023
Publication Date 2023-09
Deposit Date Mar 8, 2023
Publicly Available Date Mar 28, 2024
Journal Stroke: Vascular and Interventional Neurology
Electronic ISSN 2694-5746
Publisher Ovid Technologies (Wolters Kluwer Health)
Peer Reviewed Peer Reviewed
Volume 3
Issue 5
Article Number e000790
DOI https://doi.org/10.1161/svin.122.000790
Keywords Thrombectomy; ischemia; occlusion; stroke
Public URL https://nottingham-repository.worktribe.com/output/18229839
Publisher URL https://www.ahajournals.org/doi/full/10.1161/SVIN.122.000790

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