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Original Investigation
August 10, 2020

Endovascular Treatment After Stroke Due to Large Vessel Occlusion for Patients Presenting Very Late From Time Last Known Well

Author Affiliations
  • 1Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
  • 2Department of Clinical Neurosciences and Radiology, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 3Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
JAMA Neurol. 2021;78(1):21-29. doi:10.1001/jamaneurol.2020.2804
Key Points

Question  Does endovascular treatment benefit patients with ischemic stroke due to emergent large vessel occlusion after 16 hours?

Findings  In this case-control study of 150 patients with emergent large vessel occlusion who arrived between 16 hours and 10 days after onset, endovascular treatment was associated with favorable outcomes in dichotomatized modified Rankin Scale scores and shift of strata in modified Rankin Scale scores at 3 months, with numerically more hemorrhagic complications. Target mismatch profiles were found in approximately one-third of the study participants.

Meaning  Endovascular treatment may benefit patients with emergent large vessel occlusion and target mismatch profiles regardless of the time from onset.


Importance  Endovascular treatment (EVT) after ischemic stroke due to emergent large vessel occlusion is usually constrained by a specific window of less than 16 to 24 hours from the time the patient was last known well (LKW). Patients with slow progression and tenacious collateral circulation may persist beyond 16 hours.

Objectives  To estimate the prevalence of salvageable tissues 16 hours or more from LKW after ischemic stroke due to emergent large vessel occlusion and investigate the effectiveness of EVT in delayed large vessel occlusion.

Design, Setting and Participants  In this case-control study, from a total of 8032 patients with stroke or transient ischemic attack who were admitted between January 1, 2012, and December 31, 2018, to a single referral university hospital, 150 patients were retrospectively identified who had an acute ischemic stroke with internal carotid artery or middle cerebral artery occlusion, had a baseline National Institutes of Health Stroke Scale score of 6 or more, and arrived 16 hours or more from time LKW. The decision for EVT was made by a treating physician according to the institutional protocol.

Main Outcomes and Measures  Baseline ischemic core, collateral circulation status, and computed tomographic or magnetic resonance perfusion parameters were retrospectively quantified. Follow-up images, evaluated a median of 93 hours (interquartile range, 66-120 hours) after arrival, were used to assess the final infarct and hemorrhagic transformation. The main outcome was the modified Rankin Scale score at 90 days.

Results  For 150 patients (81 men [54%]; mean [SD] age at onset, 70.1 [13.0] years; median National Institutes of Health Stroke Scale score, 12 [interquartile range, 8-18]), the median ischemic core volume was 11.5 mL (interquartile range, 0-39.1 mL), the median penumbra volume (>6 seconds) was 55.0 mL (interquartile range, 15-128 mL), and the median mismatch ratio was 4.0 (interquartile range, 0.9-18.3). By the imaging inclusion criteria for EVT trials, there were 50 DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-up and Late Presenting Strokes Undergoing Neurointervention With Trevo)–eligible patients (33%), 58 DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke)–eligible patients (39%), and 57 ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times)–eligible patients (38%). Endovascular treatment was performed for 24 patients (16%). In propensity score–matched analyses, EVT was associated with better odds of a 90-day modified Rankin Scale score of 0 to 2 (adjusted odds ratio, 11.08 [95% CI, 1.88-108.60]) and a 90-day modified Rankin Scale score shift (common adjusted odds ratio, 5.17 [95% CI, 1.80-15.62]). Type 2 parenchymal hemorrhage was seen in 3 of 24 patients (13%) who received EVT and in 4 of 126 patients (3%) who received medical management (adjusted odds ratio, 4.06 [95% CI, 0.63-26.30]). In a subgroup of 109 patients who were 24 hours from time LKW, EVT was associated with a favorable mRS shift (common adjusted odds ratio, 10.54 [95% CI, 2.18-59.34]).

Conclusions and Relevance  This study suggests that patients with anterior circulation large vessel occlusion presenting very late (>16 hours to 10 days) from the time they were LKW may benefit from EVT.

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