Endovascular therapy in late stroke presentation may confer modest functional improvements
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Endovascular therapy for stroke due to anterior circulation large-vessel occlusion resulted in modestly better functional outcomes compared with medical therapy, even with presentation delay of more than 16 hours, researchers reported.
The study, published in JAMA Neurology, assessed the baseline characteristics of 150 patients with acute ischemic stroke, internal carotid artery or middle cerebral artery occlusion, baseline NIH Stroke Scale score of at least six and were admitted at least 16 hours from the time the patients were last known well.
“These very late arrivers usually missed their chance for recanalization treatments because they already passed the time window. However, they may benefit from endovascular recanalization treatments,” Beom Joon Kim, MD, PhD, associate professor in the department of neurology and cerebrovascular center at the Seoul National University Bundang Hospital, South Korea, and colleagues wrote. “Stroke physicians will consider first taking perfusion images or collateral images to assess the presence of salvageable tissues in patients with large-vessel occlusion, regardless of the time passed since their time of last known well. As we found, around one-third of patients harbor ‘salvageable tissues.’”
For this cohort (mean age, 70 years; 54% men; median NIH Stroke Scale score, 12) the median time between the time the patients were last known well and stroke onset was 43.5 hours (interquartile range, 22.8-76.9 hours).
When investigators applied eligibility criteria for selected trials, 33% of the cohort met requirements for the DAWN trial, 39% met requirements for the DEFUSE 3 trial and 38% met requirements for the ESCAPE trial.
Patients who underwent endovascular therapy had similar clinical profiles to those who received medical therapy. However, patients who underwent endovascular therapy had greater frequency of unwitnessed stroke onset (63% vs. 46%), were less dependent during the pre-stroke period (17% vs. 29%) and had shorter delay between the time they were last known well and presentation with stroke (median, 26.3 hours vs. 48 hours hours).
Moreover, endovascular treatment was associated with greater odds of having a modified Rankin score of 0 to 2 at 3 months post-stroke (adjusted OR = 11.08; 95% CI, 1.88-108.6) in addition to increased odds of having an overall favorable change in modified Rankin score (aOR = 5.17; 95% CI, 1.8-15.62). Among patients who presented 24 hours from the time they were last known well, endovascular treatment was associated with a favorable change in Rankin score (aOR = 10.54; 95% CI, 2.18-59.34).
“I hope for stroke physicians to assess the presence of salvageable tissues regardless of time and get the clot out of there,” Kim said in an interview. “Endovascular treatment requires a lot of medical resources; vascular neurologists, experienced neurointerventionalists, radiology technicians and nurses and navigating through the twined cerebral artery may not be straightforward. However, there may remain an opportunity to treat, which may disappear after several days.”
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