Extended window for stroke thrombectomy

Brian Snelling, David McCarthy, Stephanie Chen, Samir Sur, Omar Elwardany, Dallas Sheinberg, Dileep R Yavagal, Eric Peterson, Robert Starke

Research output: Contribution to journalArticle

Abstract

Objective: Mechanical thrombectomy is the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) up to 6 h after onset. Recent trials have demonstrated a benefit for wake-up strokes and patients beyond 6 h. Methods: A systematic literature review was conducted for multicenter randomized clinical trials (RCTs) investigating endovascular stroke treatment using perfusion imaging to identify patients that may benefit from mechanical thrombectomy for AIS beyond 6 h of onset. Random effects meta-analysis was used to analyze the following outcomes: 90-day functional independence rates with modified Rankin Scale (mRS ≤2), 90-day mortality, and symptomatic intracranial hemorrhage (sICH) rates. Further stratification was carried out by age and presentation. Results: Two multicenter RCT's were included as follows: DAWN and DEFUSE-3. Pooled 90-day functional independence rates favored endovascular management (odds ratio [OR] 5.01; P < 0.00001). Subgroup analysis demonstrated continued 90-day functional independence benefit for endovascular management regardless of age (≥80 years, OR 5.65, P = 0.01; ≤80 years, OR 4.92, P < 0.00001). When stratified for the manner of stroke discovery, 90-day functional independence rates favored endovascular management for wake-up strokes (OR 8.74, P < 0.00001) and known-time onset strokes (OR 5.08, 95% confidence interval [CI] 2.04-12.65, P = 0.0005), although no benefit was observed for unwitnessed strokes (OR 1.64, 95% CI 0.17-16.04, P = 0.67). No difference observed in 90-day mortality rates (OR 0.71; P = 0.14) or in SICH rates (OR 1.67; P = 0.29). Conclusions: This meta-analysis reinforces that endovascular management is superior to standard medical management alone for the treatment of AIS due to LVO beyond 6 h of onset in patients with perfusion-imaging selection.

Original languageEnglish (US)
Pages (from-to)294-300
Number of pages7
JournalJournal of Neurosciences in Rural Practice
Volume10
Issue number2
DOIs
StatePublished - Apr 1 2019

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Thrombectomy
Stroke
Odds Ratio
Perfusion Imaging
Meta-Analysis
Confidence Intervals
Mortality
Intracranial Hemorrhages
Therapeutics
Randomized Controlled Trials

Keywords

  • DAWN
  • DEFUSE
  • ischemic stroke
  • perfusion
  • thrombectomy

ASJC Scopus subject areas

  • Neuroscience(all)
  • Clinical Neurology

Cite this

Snelling, B., McCarthy, D., Chen, S., Sur, S., Elwardany, O., Sheinberg, D., ... Starke, R. (2019). Extended window for stroke thrombectomy. Journal of Neurosciences in Rural Practice, 10(2), 294-300. https://doi.org/10.4103/jnrp.jnrp_365_18

Extended window for stroke thrombectomy. / Snelling, Brian; McCarthy, David; Chen, Stephanie; Sur, Samir; Elwardany, Omar; Sheinberg, Dallas; Yavagal, Dileep R; Peterson, Eric; Starke, Robert.

In: Journal of Neurosciences in Rural Practice, Vol. 10, No. 2, 01.04.2019, p. 294-300.

Research output: Contribution to journalArticle

Snelling, B, McCarthy, D, Chen, S, Sur, S, Elwardany, O, Sheinberg, D, Yavagal, DR, Peterson, E & Starke, R 2019, 'Extended window for stroke thrombectomy', Journal of Neurosciences in Rural Practice, vol. 10, no. 2, pp. 294-300. https://doi.org/10.4103/jnrp.jnrp_365_18
Snelling B, McCarthy D, Chen S, Sur S, Elwardany O, Sheinberg D et al. Extended window for stroke thrombectomy. Journal of Neurosciences in Rural Practice. 2019 Apr 1;10(2):294-300. https://doi.org/10.4103/jnrp.jnrp_365_18
Snelling, Brian ; McCarthy, David ; Chen, Stephanie ; Sur, Samir ; Elwardany, Omar ; Sheinberg, Dallas ; Yavagal, Dileep R ; Peterson, Eric ; Starke, Robert. / Extended window for stroke thrombectomy. In: Journal of Neurosciences in Rural Practice. 2019 ; Vol. 10, No. 2. pp. 294-300.
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abstract = "Objective: Mechanical thrombectomy is the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) up to 6 h after onset. Recent trials have demonstrated a benefit for wake-up strokes and patients beyond 6 h. Methods: A systematic literature review was conducted for multicenter randomized clinical trials (RCTs) investigating endovascular stroke treatment using perfusion imaging to identify patients that may benefit from mechanical thrombectomy for AIS beyond 6 h of onset. Random effects meta-analysis was used to analyze the following outcomes: 90-day functional independence rates with modified Rankin Scale (mRS ≤2), 90-day mortality, and symptomatic intracranial hemorrhage (sICH) rates. Further stratification was carried out by age and presentation. Results: Two multicenter RCT's were included as follows: DAWN and DEFUSE-3. Pooled 90-day functional independence rates favored endovascular management (odds ratio [OR] 5.01; P < 0.00001). Subgroup analysis demonstrated continued 90-day functional independence benefit for endovascular management regardless of age (≥80 years, OR 5.65, P = 0.01; ≤80 years, OR 4.92, P < 0.00001). When stratified for the manner of stroke discovery, 90-day functional independence rates favored endovascular management for wake-up strokes (OR 8.74, P < 0.00001) and known-time onset strokes (OR 5.08, 95{\%} confidence interval [CI] 2.04-12.65, P = 0.0005), although no benefit was observed for unwitnessed strokes (OR 1.64, 95{\%} CI 0.17-16.04, P = 0.67). No difference observed in 90-day mortality rates (OR 0.71; P = 0.14) or in SICH rates (OR 1.67; P = 0.29). Conclusions: This meta-analysis reinforces that endovascular management is superior to standard medical management alone for the treatment of AIS due to LVO beyond 6 h of onset in patients with perfusion-imaging selection.",
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AU - Peterson, Eric

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