IMPORTANCELimited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. OBJECTIVE To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early Open Access. This is an open access article distributed under the terms of the CC-BY-NC-ND License.

BackgroundRecent clinical trials have shown that mechanical thrombectomy is superior to medical management for large vessel occlusion for up to 24 hours from onset. Our objective is to examine the safety and efficacy of thrombectomy beyond the standard of care window.MethodsA retrospective review was undertaken of the multicenter Stroke Thrombectomy and Aneurysm Registry (STAR). We identified patients who underwent mechanical thrombectomy for large vessel occlusion beyond 24 hours. We selected a matched control group from patients who underwent thrombectomy in the 6–24-hour window. We used functional independence at 3 months as our primary outcome measure.ResultsWe identified 121 patients who underwent thrombectomy beyond 24 hours and 1824 in the 6–24-hour window. We selected a 2:1 matched group of patients with thrombectomy 6–24 hours as a comparison group. Patients undergoing thrombectomy beyond 24 hours were less likely to be independent at 90 days (18 (18.8%) vs 73 (34.9%), P=0.005). They had higher odds of mortality at 90 days in the adjusted analysis (OR 2.34, P=0.023). Symptomatic intracerebral hemorrhage and other complications were similar in the two groups. In a multivariate analysis only lower number of attempts was associated with good outcomes (OR 0.27, P=0.022).ConclusionsMechanical thrombectomy beyond 24 hours appears to be safe and tolerable with no more hemorrhages or complications compared with standard of care thrombectomy. Outcomes and mortality in this time window are worse compared with an earlier time window, but the rates of good outcomes may justify this therapy in selected patients.

Long-awaited positive trial data have shown the efficacy of endovascular treatment in patients with ischemic stroke who arrive at the hospital within the first 6 hours with large-vessel occlusion of the anterior circulation. With the introduction of stent retrievers (SRs) for mechanical thrombectomy, efficient and safe large-artery recanalization treatment can be achieved. However, sometimes there are patients who do not attain complete flow restoration following attempts with traditional maneuvers. The authors present the case of a 57-year-old man with acute ischemic stroke due to an M embolus that extended into both M trunks. This patient was successfully treated with an innovative technique in which a Solitaire SR (Covidien) and a Catch SR (Balt) were used in a "Y" configuration, for which the authors coined the term "Y-stent retriever."

BACKGROUND Mechanical thrombectomy has become the first‐line treatment strategy for patients with large‐vessel occlusion strokes. Often >1 thrombectomy maneuver is necessary to achieve reperfusion. A first‐pass (FP) effect with improved functional outcomes after mechanical thrombectomy has been described. Aim of the present study is to investigate the FP effect in a large, international, multicenter stroke database. METHODS Patients who underwent mechanical thrombectomy for large‐vessel occlusion stroke in the anterior cerebral circulation between January 2014 and January 2021 and achieved complete reperfusion were identified from the STAR (Stroke Thrombectomy and Aneurysm Registry). We compared functional outcomes of patients with FP (defined as modified treatment in cerebral ischemia score 3 after a single thrombectomy maneuver) versus multiple‐pass complete reperfusion (defined as modified treatment in cerebral ischemia 3 after ≥1 thrombectomy maneuver). RESULTS A total of 1481 patients with anterior circulation large‐vessel occlusion stroke and successful recanalization were included in the analysis. FP complete recanalization was achieved in 778 patients versus 703 patients with multiple‐pass complete reperfusion. Patients with FP complete recanalization had higher Alberta Stroke Programme Early CT [Computed Tomography] Score at baseline (9 [7–10] versus 8 [7–10]; P =0.002), were less likely to be men (47% versus 51%; P =0.078) and to have intracranial internal carotid artery occlusions (14% versus 27%), as well as more likely to have M1/M2 occlusions (86% versus 73%; P <0.001), diabetes (28% versus 24%; P =0.076), and atrial fibrillation (37% versus 32%; P =0.064). FP complete recanalization (odds ratio [OR], 1.49; P =0.026), lower age (OR, 0.966; P <0.010), lower prestroke modified Rankin scale score (OR, 0.601; P <0.001), diabetes (OR, 0.612; P =0.014), and higher Alberta Stroke Programme Early CT Score (OR, 1.183; P <0.001) were independent predictors of favorable functional outcome (defined as modified Rankin scale score ≤2). In a subgroup analysis, the effect of FP complete reperfusion on favorable outcome was only detectable in patients with M1 occlusions (OR, 1.667; P =0.045). Predictors for FP reperfusion success were lower National Institutes of Health Stroke Scale score at baseline (OR, 0.980; P =0.020) and M1 occlusions (OR, 1.990; P <0.001). CONCLUSIONS This analysis of a large, multicenter stroke database confirms the importance of FP reperfusion in endovascular stroke care.

ImportanceThere is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy.ObjectiveTo assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI).Design, Setting, and ParticipantsIn this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022.ExposuresSelection by NCCT, CTP, or DWI.Main Outcomes and MeasuresPrimary outcome was functional independence (modified Rankin scale 0-2) at 90 days.ResultsAmong 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups.Conclusions and RelevanceIn this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.