Noncontrast CT Selected Thrombectomy vs Medical Management for Late-Window Anterior Large Vessel Occlusion

Research output: Contribution to journalResearch articleContributedpeer-review

Contributors

  • Thanh N Nguyen - , Boston Medical Center (BMC) (Author)
  • Raul G Nogueira - , Boston Medical Center (BMC) (Author)
  • Muhammad M Qureshi - , Boston Medical Center (BMC) (Author)
  • Simon Nagel - , Klinikum Ludwigshafen (Author)
  • Jean Raymond - , Centre Hospitalier de l'Université de Montreal (CHUM) (Author)
  • Mohamad Abdalkader - , Boston Medical Center (BMC) (Author)
  • Jelle Demeestere - , KU Leuven (Author)
  • João Pedro Marto - , Western Lisbon Hospital Centre (CHLO) (Author)
  • Sunil A Sheth - , McGovern Medical School (Author)
  • Volker Puetz - , Department of Neurology, Dresden Neurovascular Center (Author)
  • Anne Dusart - , CHU de Charleroi (Author)
  • Patrik Michel - , University Hospital of Lausanne (Author)
  • Marc Ribo - , Vall d'Hebron University Hospital (Author)
  • Osama O Zaidat - , Mercy Health, Ohio (Author)
  • James E Siegler - , The University of Chicago (Author)
  • Diogo C Haussen - , Grady Health System (Author)
  • Daniel Strbian - , Helsinki University Hospital (HUS) (Author)
  • Hilde Henon - , Université de Lille (Author)
  • Mahmoud H Mohammaden - , Grady Health System (Author)
  • Markus A Möhlenbruch - , University Hospital Heidelberg (Author)
  • Marta Olive-Gadea - , Vall d'Hebron University Hospital (Author)
  • Ajit S Puri - , University of Massachusetts Medical School (Author)
  • Simon Winzer - , Dresden Neurovascular Center, Department of Neurology (Author)
  • Johannes Kaesmacher - , Inselspital University Hospital Bern (Author)
  • Piers Klein - , Boston Medical Center (BMC) (Author)
  • Liisa Tomppo - , Helsinki University Hospital (HUS) (Author)
  • Francois Caparros - , Université de Lille (Author)
  • João Nuno Ramos - , Western Lisbon Hospital Centre (CHLO) (Author)
  • Mouhammad A Jumaa - , University of Toledo (Author)
  • Syed F Zaidi - , University of Toledo (Author)
  • Nicolas Martinez-Majander - , Helsinki University Hospital (HUS) (Author)
  • Stefania Nannoni - , University of Cambridge (Author)
  • Lieselotte Vandewalle - , University Hospitals Leuven (Author)
  • Flavio Bellante - , CHU de Charleroi (Author)
  • Mudassir Farooqui - , University of Iowa (Author)
  • Sergio Salazar-Marioni - , McGovern Medical School (Author)
  • Pekka Virtanen - , Helsinki University Hospital (HUS) (Author)
  • Daniel P O Kaiser - , Dresden Neurovascular Center, Institute and Polyclinic of Diagnostic and Interventional Neuroradiology (Author)
  • Anke Wouters - , University Hospitals Leuven (Author)
  • Rita Ventura - (Author)
  • Jessica Jesser - , University Hospital Heidelberg (Author)
  • Adnan Mujanovic - , Inselspital University Hospital Bern (Author)
  • Liqi Shu - , Rhode Island Hospital (Author)
  • Alicia C Castonguay - , University of Toledo (Author)
  • Zain Mansoor - , Boston Medical Center (BMC) (Author)
  • Zhongming Qiu - , The 903rd Hospital of the Chinese People's Liberation Army (Author)
  • Hesham E Masoud - , Syracuse University (Author)
  • Manuel Requena - , Vall d'Hebron University Hospital (Author)
  • Erno Peltola - , Helsinki University Hospital (HUS) (Author)
  • Wei Hu - , The First Affiliated Hospital of USTC China (Author)
  • Eugene Lin - , Mercy Health, Ohio (Author)
  • Kanta Tanaka - , National Cerebral and Cardiovascular Center (Author)
  • Charlotte Cordonnier - , Université de Lille (Author)
  • Daniel Roy - , Centre Hospitalier de l'Université de Montreal (CHUM) (Author)
  • Shadi Yaghi - , Rhode Island Hospital (Author)
  • Davide Strambo - , University Hospital of Lausanne (Author)
  • Hiroshi Yamagami - , National Hospital Organization Osaka Medical Center (Author)
  • Urs Fischer - , University Hospital Basel (Author)
  • Tudor G Jovin - , Cooper University Hospital (Author)
  • Robin Lemmens - , University Hospitals Leuven (Author)
  • Peter A Ringleb - , University Hospital Heidelberg (Author)
  • Santiago Ortega-Gutierrez - , University of Iowa (Author)

Abstract

BACKGROUND AND OBJECTIVES: There is uncertainty whether patients with large vessel occlusion (LVO) presenting in the late 6-hour to 24-hour time window can be selected for endovascular therapy (EVT) by noncontrast CT (NCCT) and CT angiography (CTA) for LVO detection. We evaluated the clinical outcomes of patients selected for EVT by NCCT compared with those medically managed in the extended time window.

METHODS: This multinational cohort study was conducted at 66 sites across 10 countries. Consecutive patients with proximal anterior LVO stroke selected for EVT by NCCT or medically managed and presenting within 6-24 hours of time last seen well (TSLW) from January 2014 to May 2022 were included. The primary end point was the 90-day ordinal shift in the modified Rankin Scale (mRS) score. Inverse probability treatment weighting (IPTW) and multivariable methods were used.

RESULTS: Of 5,098 patients screened, 839 patients were included, with a median (interquartile range) age of 75 (64-83) years; 455 (54.2%) were women. There were 616 patients selected to undergo EVT by NCCT (73.4%) and 223 (26.6%) who were medically managed. In IPTW analyses, there was a more favorable 90-day ordinal mRS shift in patients selected by NCCT to EVT vs those who were medically managed (odds ratio [OR] 1.99, 95% CI 1.53-2.59; p < 0.001). There were higher rates of 90-day functional independence (mRS 0-2) in the EVT group (40.1% vs 18.4%, OR 3.31, 95% CI 2.11-5.20; p < 0.001). sICH was nonsignificantly higher in the EVT group (8.5% vs 1.4%, OR 3.77, 95% CI 0.72-19.7, p = 0.12). Mortality at 90 days was lower in the EVT vs MM group (23.9% vs 32.3%, OR 0.61, 95% CI 0.45-0.83, p = 0.002).

DISCUSSION: In patients with proximal anterior LVO in the extended time window, there was a lower rate of disability and mortality in patients selected with NCCT and CTA to EVT compared with those who were medically managed. These findings support the use of NCCT as a simpler and more inclusive approach to patient selection in the extended window.

TRIAL REGISTRATION INFORMATION: This study was registered at ClinicalTrials.gov under NCT04096248.

CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with proximal anterior circulation occlusion presenting with ischemic stroke from 6 to 24 hours, compared with medical management, those undergoing thrombectomy based on NCCT have reduced disability and mortality at 90 days.

Details

Original languageEnglish
Article numbere209324
Pages (from-to)e209324
JournalNeurology
Volume102
Issue number10
Publication statusPublished - 28 May 2024
Peer-reviewedYes

External IDs

ORCID /0000-0001-5258-0025/work/159172044

Keywords

Keywords

  • Humans, Female, Aged, Male, Thrombectomy/methods, Aged, 80 and over, Middle Aged, Endovascular Procedures/methods, Computed Tomography Angiography, Tomography, X-Ray Computed, Cohort Studies, Time-to-Treatment, Treatment Outcome, Cerebral Angiography