Late Thrombectomy in Clinical Practice : Retrospective Application of DAWN/DEFUSE3 Criteria within the German Stroke Registry

Abstract

Background and purpose: To provide real-world data on outcome and procedural factors of late thrombectomy patients.

Methods: We retrospectively analyzed patients from the multicenter German Stroke Registry. The primary endpoint was clinical outcome on the modified Rankin scale (mRS) at 3 months. Trial-eligible patients and the subgroups were compared to the ineligible group. Secondary analyses included multivariate logistic regression to identify predictors of good outcome (mRS ≤ 2).

Results: Of 1917 patients who underwent thrombectomy, 208 (11%) were treated within a time window ≥ 6-24 h and met the baseline trial criteria. Of these, 27 patients (13%) were eligible for DAWN and 39 (19%) for DEFUSE3 and 156 patients were not eligible for DAWN or DEFUSE3 (75%), mainly because there was no perfusion imaging (62%; n = 129). Good outcome was not significantly higher in trial-ineligible (27%) than in trial-eligible (20%) patients (p = 0.343). Patients with large trial-ineligible CT perfusion imaging (CTP) lesions had significantly more hemorrhagic complications (33%) as well as unfavorable outcomes.

Conclusion: In clinical practice, the high number of patients with a good clinical outcome after endovascular therapy ≥ 6-24 h as in DAWN/DEFUSE3 could not be achieved. Similar outcomes are seen in patients selected for EVT ≥ 6 h based on factors other than CTP. Patients triaged without CTP showed trends for shorter arrival to reperfusion times and higher rates of independence.

Keywords: Endovascular therapy; Late thrombectomy; Outcome; Stroke.

Conflict of interest statement

M. Herzberg, K. Scherling, R. Stahl, S. Tiedt, F.A. Wollenweber, C. Küpper, K. Feil, R. Forbrig, M. Patzig, L. Kellert, W.G. Kunz, P. Reidler, H. Zimmermann, T. Liebig, M. Dieterich and F. Dorn declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1

Flowchart shows patient selection and exclusion criteria. BA basilar artery, ICA internal carotid artery, LSW last seen well, MCA middle cerebral artery, mRS modified Rankin scale, NIHSS National Institutes of Health Stroke Scale, PCA posterior cerebral artery, pmRS premorbid modified Rankin scale, SO symptom onset. ‡ multiple missing data possible, * multiple occlusion sites possible, † note the overlap of 14 patients

Fig. 2

Estimated infarct volume (ml) in correlation to the results on the modified Rankin scale (mRS) at 90 days. The figure suggests a trend for positive linear association between the volume of the infarction core and mRS90; however this finding was not statistically significant (p = 0.673)

Fig. 3

Distribution of scores on the modified Rankin Scale (mRS) at 90 days. Shown is the shift analysis of scores on the modified Ranking Scale within the GSR and its subgroups compared to the RCT’s original results. DAWN/DEFUSE3 (GSR) represents all trial-eligible patients that received ET plus standard medical therapy between 6 to 24 h. Non-DAWN-Non-DEFUSE3 (GSR) represents all trial-ineligible patients that received ET plus standard medical therapy between 6 to 24 h. DAWN-/DEFUSE3-thrombectomy are the RCT’s original results of the thrombectomy group. The numbers in the bars are percentages of patients who had each score; the percentages may not sum to 100 because of rounding. Scores on the modified Rankin scale range from 0 to 6, with 0 indicating no symptoms, 1 no clinically significant disability, 2 slight disability, 3 moderate disability, 4 moderately severe disability, 5 severe disability, and 6 death

Fig. 4

Subgroup analyses good clinical outcome. The forest plot in a shows the significant common odds ratio (OR) for good outcome (defined as a score on the modified Ranking Scale of 0 to 2 or back to baseline) at 90 days. Unfavorable outcome is defined as modified Rankin Scale 3–6. b shows the odds ratio adjusted for age, premorbid modified Ranking Scale 0 (pmRS 0), National Institutes of Health Stroke Scale (NIHSS), and modified thrombolysis in cerebral infarction (mTICI score). aOR, adjusted odds ratio. The size of the squares is proportional to the number of patients in the subgroup. p ≤ 0.05 was considered significant, Wald CI Wald confidence interval, Chisq Chi-squared test