Simplified stroke imaging selection modality for endovascular thrombectomy in the extended time window: systematic review and meta-analysis

Abstract

BackgroundThe impact of imaging selection modality on clinical outcomes of endovascular thrombectomy (EVT) in the 6–24-hour time window remains undetermined. We compared the clinical outcomes of a simplified stroke imaging selection modality using non-contrast computed tomography (NCCT)±CT angiography (CTA) with using advanced CT perfusion (CTP).MethodsPubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception to 1 May 2022 to compare NCCT±CTA and CTP for patient selection for EVT in late-presenting stroke with large vessel occlusions (LVO). The primary outcome was the proportion of patients achieving functional independence (modified Rankin Scale score 0–2) within 180 days. The secondary outcomes included mortality within 90 days, successful recanalization, and any intracranial hemorrhage.ResultsA total of 3419 patients in six articles were included in this meta-analysis. There was no significant difference between NCCT±CTA (no-CTP) and CTP in functional independence either in overall or subgroup analysis. However, the mortality in the no-CTP group was higher than in the CTP group. Furthermore, within the DAWN/DEFUSE 3-like subgroup, there were no significant differences in mortality, successful recanalization, and any intracranial hemorrhage between the two groups.ConclusionThere was no significant difference between the simplified NCCT±CTA modality and the advanced CTP modality. The use of NCCT±CTA may represent a reasonable option for selecting patients for EVT in the extended time window, especially in the absence of CTP and acute phase MRI capabilities.

Thrombectomy for Anterior Circulation Stroke in a Witnessed Late Time Window Versus Early Time Window

“…16 The very poor natural history of anterior circulation large vessel occlusion also indicates to us a great potential benefit of thrombectomy based even on simple, pragmatic criteria like baseline NIHSS ≥ 6 and baseline non-contrast CT scans (ASPECTS ≥ 5). 13 In the present study, which sought to precisely assess the outcomes of thrombectomy in the late time window under pragmatic criteria, we included in the analysis only patients treated in a known late time window (> 6 hours), with NIHSS ≥ 6 and ASPECTS ≥ 5. The control group comprised patients presenting with the same characteristics but treated within the standard early time window.…”

“…16 The very poor natural history of anterior circulation large vessel occlusion also indicates to us a great potential benefit of thrombectomy based even on simple, pragmatic criteria like baseline NIHSS ≥ 6 and baseline non-contrast CT scans (ASPECTS ≥ 5). 13…”

“…Moreover, to our knowledge there is not yet a randomized clinical trial to support selection of patients in late-window purely by ASPECTS. 13 The aim of this study was to assess the outcomes of thrombectomy in the treatment of patients presenting with anterior circulation large vessel stroke in a witnessed late time window of more than 6 hours selected based on pragmatic criteria.…”

“…Moreover, to our knowledge there is not yet a randomized clinical trial to support selection of patients in late-window purely by ASPECTS. 13…”

Clinical Uncertainty in Large Vessel Occlusion ischemic stroke (CULVO): Does automated perfusion scanning make a difference? Protocol of an intrarater and interrater agreement study

“…Moreover, a recent large retrospective observational study, CLEAR, found that ELVIS patients undergoing EVT utilizing non-perfusion CT imaging for decision-making had comparable clinical outcomes compared to those that utilized perfusion CT or magnetic resonance imaging [ 18 ]. Systematic reviews comparing outcomes between late-window ELVIS patients who obtain non-perfusion CT and perfusion CT prior to undergoing EVT do not show a significant difference in benefit in terms of clinical outcomes [ 19 , 20 ]. However, these reviews are all based on observational data from large databases.…”