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Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability

2022; Lippincott Williams & Wilkins; Volume: 100; Issue: 7 Linguagem: Inglês

10.1212/wnl.0000000000201543

1526-632X

James E. Siegler, Muhammad M. Qureshi, Raul G. Nogueira, Kanta Tanaka, Simon Nagel, Patrik Michel, Nicholas Vigilante, Marc Ribó, Hiroshi Yamagami, Shinichi Yoshimura, Mohamad Abdalkader, Diogo C Haussen, Mahmoud Mohammaden, Stefania Nannoni, Markus Möhlenbruch, Hilde Hénon, Sunil A. Sheth, Santiago Ortega‐Gutiérrez, Marta Olivé‐Gadea, François Caparros, Fatih Şeker, Syed Hassan Ejaz Zaidi, Alicia C. Castonguay, Kazutaka Uchida, Nobuyuki Sakai, Ajit S Puri, Mudassir Farooqui, Ḱazunori Toyoda, Sergio Salazar‐Marioni, Masataka Takeuchi, Behzad Farzin, Hesham Masoud, Anna Luisa Kühn, Ameena Rana, Masafumi Morimoto, Masunari Shibata, Tadashi Nonaka, Piers Klein, Anvitha Sathya, Nicole L. Kiley, Charlotte Cordonnier, Davide Strambo, Jelle Demeestere, Peter A. Ringleb, Daniel Roy, Osama O. Zaidat, Tudor Jovin, Johannes Kaesmacher, Urs Fischer, Jean Raymond, Thanh N. Nguyen,

Venous Thromboembolism Diagnosis and Management

Background and Objectives Current guidelines do not address recommendations for mechanical thrombectomy (MT) in the extended time window (>6 hours after time last seen well [TLSW]) for large vessel occlusion (LVO) patients with preexisting modified Rankin Scale (mRS) > 1. In this study, we evaluated the outcomes of MT vs medical management in patients with prestroke disability presenting in the 6- to 24-hour time window with acute LVO. Methods We analyzed a multinational cohort (61 sites, 6 countries from 2014 to 2020) of patients with prestroke (or baseline) mRS 2 to 4 and anterior circulation LVO treated 6–24 hours from TLSW. Patients treated in the extended time window with MT vs medical management were compared using multivariable logistic regression and inverse probability of treatment weighting (IPTW). The primary outcome was the return of Rankin (ROR, return to prestroke mRS by 90 days). Results Of 554 included patients (448 who underwent MT), the median age was 82 years (interquartile range [IQR] 72–87) and the National Institutes of Health Stroke Scale (NIHSS) was 18 (IQR 13–22). In both MV logistic regression and IPTW analysis, MT was associated with higher odds of ROR (adjusted OR [aOR] 3.96, 95% CI 1.78–8.79 and OR 3.10, 95% CI 1.20–7.98, respectively). Among other factors, premorbid mRS 4 was associated with higher odds of ROR (aOR, 3.68, 95% CI 1.97–6.87), while increasing NIHSS (aOR 0.90, 95% CI 0.86–0.94) and decreasing Alberta Stroke Program Early Computed Tomography Scale score (aOR per point 0.86, 95% CI 0.75–0.99) were associated with lower odds of ROR. Age, intravenous thrombolysis, and occlusion location were not associated with ROR. Discussion In patients with preexisting disability presenting in the 6- to 24-hour time window, MT is associated with a higher probability of returning to baseline function compared with medical management. Classification of Evidence This investigation9s results provide Class III evidence that in patients with preexisting disability presenting 6–24 hours from the TLSW and acute anterior LVO stroke, there may be a benefit of MT over medical management in returning to baseline function.