Endovascular Therapy for Stroke Presenting Beyond 24 Hours

Abstract

ImportancePrevious randomized clinical trials (RCTs) have supported the use of endovascular therapy (EVT) in late-window acute ischemic stroke (AIS; 6-24 hours). However, little is known about the use of EVT in very late-window AIS (>24 hours).ObjectiveTo examine outcomes following EVT for very late-window AIS.Data SourcesA systematic review of the English language literature was conducted using Web of Science, Embase, Scopus, and PubMed to search for articles published from database inception until December 13, 2022.Study SelectionThis systematic review and meta-analysis included published studies regarding very late-window AIS treated with EVT. Multiple reviewers screened studies, and an extensive manual search of the references of included articles was performed to identify any missed articles. Of the 1754 initially retrieved studies, 7 published between 2018 and 2023 were ultimately included.Data Extraction and SynthesisData were extracted independently by multiple authors and evaluated for consensus. Data were pooled using a random-effects model. This study is reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guideline, and the protocol was prospectively registered with PROSPERO.Main Outcomes and MeasuresThe primary outcome of interest was functional independence, as assessed with 90-day modified Rankin Scale (mRS) scores (0-2). Secondary outcomes included thrombolysis in cerebral infarction (TICI) scores (2b-3 or 3), symptomatic intracranial hemorrhage (sICH), 90-day mortality, early neurological improvement (ENI), and early neurological deterioration (END). Frequencies and means were pooled with the corresponding 95% CIs.ResultsThis review included 7 studies involving a total of 569 patients. The mean baseline National Institutes of Health Stroke Scale score was 13.6 (95% CI, 11.9-15.5), and the mean Alberta Stroke Program Early CT Score was 7.9 (95% CI, 7.2-8.7). The mean time from last known well and/or onset to puncture was 46.2 hours (95% CI, 32.4-65.9 hours). Frequencies for the primary and secondary outcomes were 32.0% (95% CI, 24.7%-40.2%) for functional independence (90-day mRS scores of 0-2) and 81.9% (95% CI, 78.5%-84.9%) for TICI scores of 2b to 3, 45.3% (95% CI, 36.6%-54.4%) for TICI scores of 3, 6.8% (95% CI, 4.3%-10.7%) for sICH, and 27.2% (95% CI, 22.9%-31.9%) for 90-day mortality. In addition, frequencies were 36.9% (95% CI, 26.4%-48.9%) for ENI and 14.3% (95% CI, 7.1%-26.7%) for END.Conclusions and RelevanceIn this review, EVT for very late-window AIS was associated with favorable frequencies of 90-day mRS scores of 0 to 2 and TICI scores of 2b to 3 and with low frequencies of 90-day mortality and sICH. These results suggest that EVT may be safe and associated with improved outcomes for very late-window AIS, although RCTs and prospective, comparative studies are needed to determine which patients may benefit from very late intervention.

Heterogeneous treatment effects of Cerebrolysin as an early add-on to reperfusion therapy: post hoc analysis of the CEREHETIS trial

“…Nowadays mechanical EVT has become the standard reperfusion therapy for acute ischemic stroke due to large vessel occlusion in the anterior circulation (Powers et al, 2019). Besides early-window (<6 h) reperfusion, EVT is being extensively studied in other clinical settings: prior IVT bridging, late-window (6-24 h) and very late-window (>24 h) time frame, a large infarct core, and subsequent futile recanalization (Manning et al, 2018;Lin et al, 2022;Kobeissi et al, 2023;Sattari et al, 2023;Shen et al, 2023). However, reperfusion injury and BBB disruption leading to HT and poor outcome inevitably occur in some patients.…”

2.5-Minute Fast Brain MRI with Multiple Contrasts in Acute Ischemic Stroke

“…NeuroMix can be useful in clinical situations where fast imaging is necessary and patients may have difficulty lying still [ 6 ], like suspected ischemic stroke [ 7 ]. In acute ischemic stroke, the reperfusion treatment time window extends to the first 24 h after symptom onset if salvageable brain tissue exists [ 7 – 9 ], depending on reperfusion strategy (thrombolysis or thrombectomy) and findings on imaging [ 10 ], and may extend even beyond 24 h [ 11 ]. Imaging has to be fast [ 7 ] because earlier reperfusion treatment improves patient outcomes [ 12 ].…”

Preserved Corticospinal Tract Revealed by Acute Perfusion Imaging Relates to Better Outcome After Thrombectomy in Stroke

“…Nowadays, clinical trials provide evidence for the benefit of MT in LVO stroke up to 24 hours after symptom onset, 1,2 whereas a recent meta-analysis supports the benefit even beyond that time window. 3 Recently, the therapeutic gain in functional outcome has even been shown for patients with LVO in the anterior circulation and already large infarction, as indicated by Alberta Stroke Program Early Computed Tomography Scores (ASPECTS) of 3 to 5 or an ischemic core volume over 70 mL. 4–7 In the extended time window, the clinical decision in favor or against MT highly depends on data derived from acute magnetic resonance imaging or computed tomography–perfusion (CTP) imaging protocols mapping the ischemic core and the penumbra, the salvageable tissue at risk, in addition to demographic and clinical properties.…”