Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction

Abstract

Importance: Only limited data are available about a potential benefit associated with endovascular treatment (EVT) for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction.

Objective: To assess the association of recanalization after EVT with functional outcomes for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction.

Design, setting, and participants: This retrospective, multicenter cohort study included patients enrolled in the German Stroke Registry-Endovascular Treatment with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less who presented between 6 and 24 hours after stroke onset and underwent computed tomography and subsequent EVT between July 1, 2015, and December 31, 2019.

Main outcomes and measures: The primary end point was a modified Rankin Scale (mRS) score of 3 or less at day 90. The association between recanalization (defined as the occurrence of a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3) and outcome was assessed using logistic regression and inverse probability weighting analysis.

Intervention: Endovascular treatment.

Results: Of 5853 patients, 285 (5%; 146 men [51%]; median age, 73 years [IQR, 62-81 years]) met the inclusion criteria and were analyzed. Of these 285 patients, 79 (27.7%) had an mRS score of 3 or less at day 90. The rate of successful recanalization was 75% (215 of 285) and was independently associated with a higher probability of reaching an mRS score of 3 or less (adjusted odds ratio, 4.39; 95% CI, 1.79-10.72; P < .001). In inverse probability weighting analysis, a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3 was associated with a 19% increase (95% CI, 9%-29%; P < .001) in the probability for an mRS score of 3 or more. Multivariable logistic regression analysis suggested a significant treatment benefit associated with vessel recanalization in a time window of up to 17.6 hours and ASPECTS of 3 to 5. The rate of secondary symptomatic intracerebral hemorrhage was 6.3% (18 of 285).

Conclusions and relevance: In this cohort study reflecting daily clinical practice, vessel recanalization for patients with a low ASPECTS and extended time window was associated with better functional outcomes in a time window up to 17.6 hours and ASPECTS of 3 to 5. The results of this study encourage current randomized clinical trials to enroll patients with a low ASPECTS, even within the extended time window.

Conflict of interest statement

Conflict of Interest Disclosures: Drs Broocks and Meyer reported receiving compensation as a speaker from Balt and personal fees from Eppdata GmbH outside the submitted work. Drs Flottmann and Kniep reported receiving personal fees from Eppdata GmbH outside the submitted work. Dr Deb-Chatterji reported receiving grants from Werner Otto Stiftung outside the submitted work. Dr Thomalla reported receiving personal fees from Acandis, Alexion, Amarin, Bayer, Boehringer Ingelheim, Bristol Myers Squibb/Pfizer, Daiichi Sankyo, Portola, and Stryker outside the submitted work. Dr Fiehler reported receiving personal fees from Cerenovus, Medtronic, Phenox, and Penumbra outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Association of Baseline Alberta Stroke Program Early CT Score (ASPECTS) and Recanalization With Favorable Outcome

The graph illustrates the association of recanalization with favorable outcomes (modified Rankin Scale [mRS] score of 0-3) according to the baseline ASPECTS. Error bars indicate 95% CIs, which overlap for ASPECTS of 0 to 2.

Figure 2.. Association of Time and Recanalization With Estimated Favorable Outcome

The association of recanalization with outcomes is illustrated according to the existing time window. Error bars indicate 95% CIs, which overlap for a time window greater than 1056 minutes. mRS indicates modified Rankin Scale.

Figure 3.. Association of Time and Recanalization With Estimated Functional Independence

The association of recanalization with outcomes is illustrated according to the existing time window. Error bars indicate 95% CIs, which overlap for a time window greater than 828 minutes. mRS indicates modified Rankin Scale.