Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry

Abstract

Background and purpose: In acute ischaemic stroke (AIS) of the anterior circulation (AC) treated with mechanical thrombectomy (MT), data point to a decline of treatment effect with increasing time from symptom onset to treatment. However, the magnitude of the decline will depend on the clinical setting and imaging selection used. The aims of this study were (1) to evaluate the clinical effect of time to reperfusion (TTR); and (2) to assess the safety and technical efficacy of MT according to strata of TTR. Methods: Using the retrospective multicentre BEYOND-SWIFT registry data (ClinicalTrials.gov identifier: NCT03496064), we compared safety and efficacy of MT in 1461 patients between TTR strata of 0–180 min ( n = 192), 180–360 min ( n = 876) and >360 min ( n = 393). Clinical effect of TTR was evaluated using multivariable logistic regression analyses adjusting for pre-specified confounders [adjusted odds ratios (aOR) and 95% confidence intervals (95% CI)]. Primary outcome was good functional outcome (modified Rankin Scale: mRS 0–2) at day 90. Results: Every hour delay in TTR was a significant factor related to mRS 0–2 (aOR 0.933, 95% CI 0.887–0.981) with an estimated 1.5% decreased probability of good functional outcome per hour delay of reperfusion, and mRS 0–1 (aOR 0.929, 95% CI 0.877–0.985). Patients with late TTR had lower rates of successful and excellent reperfusion, higher complication rates and number of passes. Conclusions: TTR is an independent factor related to long-term functional outcome. With increasing TTR, interventional procedures become technically less effective. Efforts should be made to shorten TTR through optimized prehospital and in-hospital pathways.

Temporal Trends and Risk Factors for Delayed Hospital Admission in Suspected Stroke Patients

“…Thrombolysis has shown to improve outcome in selected patients up to 9 h after symptom onset [1], while endovascular thrombectomy lowered disability in selected patients with a large vessel occlusion up to 16-24 h after onset [2,3]. However, for endovascular treatment and thrombolysis [4][5][6] as well as conservative medical management [7] the time from symptom onset to initiation of therapy remains a decisive factor for functional outcome [6]. While efforts to reduce the door-to-treatment time have led to significant improvements [8], the development of prehospital delays in AIS remains controversial.…”

Efficacy and Safety of Endovascular Treatment for Acute Large-Vessel Ischemic Stroke Beyond 6 h After Symptom Onset: A Meta-Analysis

“…Furthermore, prior to these RCTs, several studies had challenged the 6-h time window. Some retrospective studies have shown that patients with AIS who had been treated with delayed EVT (>6 h after symptom onset) showed comparable efficacy and safety compared with patients with AIS who had been treated with early EVT (within 6 h after symptom onset) (10,11). These studies provided further evidence for delayed EVT in patients with AIS that needs consideration.…”

Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

“…Late presenters have lower rates of successful and excellent reperfusion, higher complication rates and may need increased number of passes during EVT. 118 There is no high-level evidence from RCTs proving efficacy of EVT in extended time windows without advanced neuroimaging. Real-world data from the North American Solitaire Stent Retriever Acute Stroke (NASA) and the Trevo Stent Retriever Acute Stroke (TRACK) registries suggest EVT is equally safe and effective before and after 6 h. 119 …”

“…Late presenters have lower rates of successful and excellent reperfusion, higher complication rates and may need increased number of passes during EVT. 118 There is no high-level evidence from RCTs proving efficacy of EVT in extended time windows without advanced neuroimaging. Realworld data from the North American Solitaire Stent Retriever Acute Stroke (NASA) and the Trevo Stent Retriever Acute Stroke (TRACK) registries suggest EVT is equally safe and effective before and after 6 h. 119 The arguments in favor of standard neuroimaging for extended time windows are the following: EVT is both safe and effective; initial studies have shown efficacy but had too restrictive inclusion criteria; relaxing these criteria will increase benefit for more stroke patients, not only those with the most favorable imaging profile.…”