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July 26, 2021

Selection of Patients for Thrombectomy in the Extended Time Window

Author Affiliations
  • 1Department of Neurology, Hopital Sainte-Anne, Université de Paris, Paris, France
JAMA Neurol. 2021;78(9):1051-1053. doi:10.1001/jamaneurol.2021.1825

Based on the protocols used in the DAWN (Diffusion Weighted Imaging or Computerized Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) randomized clinical trials (RCTs) of thrombectomy in the extended window, current guidelines recommend thrombectomy either in the 6- to 16-hour window in patients with a target perfusion imaging mismatch profile or in the 6- to 24-hour window in patients with a clinical imaging mismatch profile.1 However, these criteria only encompass approximately 3% of all patients with acute ischemic stroke, 6% of those presenting in the 6- to 24-hour window, and 30% of all potentially eligible patients (ie, those presenting with large-vessel occlusion and National Institutes of Health Stroke Scale [NIHSS] scores ≥6 or within the 6- to 24-hour window) eligible for thrombectomy.2 To increase the proportion of patients eligible for thrombectomy in the extended window, 3 issues need to be resolved: (1) whether the 2 mismatch profiles are equivalent in the 6- to 16-hour window (ie, whether either imaging approach can be used with similar benefit), (2) whether the target mismatch profile is equivalent to the clinical mismatch profile in the 16- to 24-hour window, and (3) whether patients with neither mismatch profile still benefit from thrombectomy in the 6- to 24-hour window compared with patients treated medically. The latter issue arises because only patients with mismatch profiles were enrolled in the DAWN and DEFUSE 3 studies, both of which compared outcomes between the thrombectomy and control arms.

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