TY - JOUR
T1 - Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients
T2 - A Subgroup Analysis from the BEST Prospective Cohort Study
AU - Siegler, James E.
AU - Messé, Steven R.
AU - Sucharew, Heidi
AU - Kasner, Scott E.
AU - Mehta, Tapan
AU - Arora, Niraj
AU - Starosciak, Amy K.
AU - De Los Rios La Rosa, Felipe
AU - Barnhill, Natasha R.
AU - Mistry, Akshitkumar M.
AU - Patel, Kishan
AU - Assad, Salman
AU - Tarboosh, Amjad
AU - Dakay, Katarina
AU - Salwi, Sanjana
AU - Wagner, Jeff
AU - Bennett, Alicia
AU - Jagadeesan, Bharathi D.
AU - Streib, Christopher
AU - Weber, Stewart A.
AU - Chitale, Rohan
AU - Volpi, John J.
AU - Mayer, Stephan A.
AU - Yaghi, Shadi
AU - Jayaraman, Mahesh
AU - Khatri, Pooja
AU - Mistry, Eva A.
N1 - Funding Information:
This study was supported by a Society of Vascular and Interventional Neurology (SVIN) pilot grant, University of Cincinnati Gardner Neuroscience Institute pilot grant, StrokeNet NCC (U01 NS086872), and StrokeNet University of Cincinnati RCC (U10 NS086512). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Publisher Copyright:
© 2019 by the Congress of Neurological Surgeons.
PY - 2020/2/1
Y1 - 2020/2/1
N2 - Because 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. OBJECTIVE: To determine the safety and efficacy of thrombectomy in DAWN/DEFUSE-3-ineligible patients. METHODS: Using 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. RESULTS: Ninety-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]). CONCLUSION: Thrombectomy 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.
AB - Because 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. OBJECTIVE: To determine the safety and efficacy of thrombectomy in DAWN/DEFUSE-3-ineligible patients. METHODS: Using 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. RESULTS: Ninety-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]). CONCLUSION: Thrombectomy 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.
KW - Acute stroke
KW - Computed tomography
KW - Perfusion imaging
KW - Thrombectomy
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UR - http://www.scopus.com/inward/citedby.url?scp=85077941724&partnerID=8YFLogxK
U2 - 10.1093/neuros/nyz485
DO - 10.1093/neuros/nyz485
M3 - Article
C2 - 31758197
AN - SCOPUS:85077941724
SN - 0148-396X
VL - 86
SP - E156-E163
JO - Clinical Neurosurgery
JF - Clinical Neurosurgery
IS - 2
ER -
