• James E Siegler, Steven R Messé, Heidi Sucharew, Scott E Kasner, Tapan Mehta, Niraj Arora, Amy K Starosciak, Felipe De Los Rios La Rosa, Natasha R Barnhill, Akshitkumar M Mistry, Kishan Patel, Salman Assad, Amjad Tarboosh, Katarina Dakay, Sanjana Salwi, Jeff Wagner, Alicia Bennett, Bharathi D Jagadeesan, Christopher Streib, Stewart A Weber, Rohan Chitale, John J Volpi, Stephan A Mayer, Shadi Yaghi, Mahesh Jayaraman, Pooja Khatri, and Eva A Mistry.
• Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania.
• Neurosurgery. 2020 Feb 1; 86 (2): E156-E163.

BackgroundBecause of the overwhelming benefit of thrombectomy for highly selected trial patients with large vessel occlusion (LVO), some trial-ineligible patients are being treated in practice.ObjectiveTo determine the safety and efficacy of thrombectomy in DAWN/DEFUSE-3-ineligible patients.MethodsUsing a multicenter prospective observational study of consecutive patients with anterior circulation LVO who underwent late thrombectomy, we compared symptomatic intracerebral hemorrhage (sICH) and good outcome (90-d mRS 0-2) among DAWN/DEFUSE-3-ineligible patients to trial-eligible patients and to untreated DAWN/DEFUSE-3 controls.ResultsNinety-eight patients had perfusion imaging and underwent thrombectomy >6 h; 46 (47%) were trial ineligible (41% M2 occlusions, 39% mild deficits, 28% ASPECTS <6). In multivariable regression, the odds of a good outcome (aOR 0.76, 95% CI 0.49-1.19) and sICH (aOR 3.33, 95% CI 0.42-26.12) were not different among trial-ineligible vs eligible patients. Patients with mild deficits were more likely to achieve a good outcome (aOR 3.62, 95% CI 1.48-8.86) and less sICH (0% vs 10%, P = .16), whereas patients with ASPECTS <6 had poorer outcomes (aOR 0.14, 95% CI 0.05-0.44) and more sICH (aOR 24, 95% CI 5.7-103). Compared to untreated DAWN/DEFUSE-3 controls, trial-ineligible patients had more sICH (13%BEST vs 3%DAWN [P = .02] vs 4%DEFUSE [P = .05]), but were more likely to achieve a good outcome at 90 d (36%BEST vs 13%DAWN [P < .01] vs 17%DEFUSE [P = .01]).ConclusionThrombectomy is used in practice for some patients ineligible for the DAWN/DEFUSE-3 trials with potentially favorable outcomes. Additional trials are needed to confirm the safety and efficacy of thrombectomy in broader populations, such as large core infarction and M2 occlusions.Copyright © 2019 by the Congress of Neurological Surgeons.

21 keywords...

hide…