Endovascular Thrombectomy for Large-Vessel Stroke Beyond 24 Hours

Anthony S. Kim, MD, reviewing Sarraj A et al. JAMA Neurol 2022 Dec 27

Randomized clinical trial data have established the efficacy of endovascular thrombectomy for selected patients with large-vessel occlusion stroke up to 24 hours after last known well time, but whether treatment beyond 24 hours would be beneficial is unclear, since randomized trial data for this ultra-extended time window are not yet available. To explore this possibility with available observational data, researchers identified 301 adults with acute large-vessel occlusion stroke involving the internal carotid artery or M1 or M2 segments of the middle cerebral artery who had received either endovascular thrombectomy (185; 61%) or medical management (116; 39%) beyond 24 hours after symptom onset at 17 centers across the U.S., Spain, Australia, and New Zealand from 2012 through 2021.

Patients who had received endovascular thrombectomy were significantly more likely to be functionally independent (modified Rankin Scale score, 0–2; 38% vs. 10%), despite an increased risk for symptomatic intracranial hemorrhage (10.1% vs. 1.7%), than those that had received medical management. Similar robust results came from a series of subsequent analyses using propensity score matching to address potential selection bias by balancing clinical characteristics and Alberta Stroke Program Early CT Score (ASPECTS); clinical characteristics and perfusion imaging parameters; and clinical characteristics, ASPECTS, and perfusion parameters.