Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.

Neurology

From the Cooper Neurological Institute (J.E.S., A.R., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Radiology (M.M.Q., M.A., P.K., A.S., N.L.K., T.N.N.), Boston Medical Center, Boston University School of Medicine, MA; Departments of Radiation Oncology (M.M.Q.) and Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (R.G.N.), University of Pittsburgh Medical Center, PA; Division of Stroke Care Unit (Kanta Tanaka, Kazunori Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology (S. Nagel), Klinikum Ludwigshafen; Departments of Neurology (S. Nagel, P.A.R.) and Neuroradiology (M.A.M., F.S.), Heidelberg University Hospital, Germany; Department of Neurology (P.M., D.S.), Lausanne University Hospital, University of Lausanne, Switzerland; Cooper Medical School of Rowan University (N.V.), Camden, NJ; Stroke Unit (M.R., M.O.-G.), Neurology, Hospital Vall D'Hebron, Barcelona, Spain; Department of Stroke Neurology (H.Y.), NHO Osaka National Hospital, Japan; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya, Japan; Department of Neurology (D.C.H., M.H.M.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Clinical Neurosciences (S. Nannoni), University of Cambridge, United Kingdom; University of Lille (H.H., F.C., C.C.), Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, France; Department of Neurology (S.A.S., S.S.-M.), UTHealth McGovern Medical School, Houston, TX; Department of Neurology (S.O.G., M.F.), University of Iowa Hospitals and Clinics, Iowa City,; Department of Neurology (S.Z., A.C.), University of Toledo, OH; Department of Neurosurgery (K.U.), Hyogo College of Medicine, Nishinomiya, Japan; Department of Neurovascular Research (N.S.), Kobe City Medical Center General Hospital, Japan; Division of Neurointerventional Radiology (A.S.P., A.L.K.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurosurgery (M.T.), Seisho Hospital, Odawara, Japan; Department of Radiology (B.F., D.R., J.R.), Centre Hospitalier de L'Université de Montréal, Canada; Department of Neurology (H.E.M.), State University of New York, Upstate Medical University, Syracuse, NY; Department of Neurosurgery (M. Morimoto), Yokohama Shintoshi Neurosurgical Hospital; Department of Neurology (M.S.), Ise Red Cross Hospital; Department of Neurosurgery (T.N.), Sapporo Shiroishi Memorial Hospital, Japan; Neurology Department (J.D.), Leuven University Hospital, Belgium; Department of Neurology (P.A.R.), Heidelberg University Hospital, Germany; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; Institute of Diagnostic and Interventional Neuroradiology (J.K.), University of Bern, Inselspital; Institute of Diagnostic (J.K.), Interventional and Pediatric Radiology, University Hospital Bern, Inselspital; Department of Neurology (U.F.), University Hospital Basel, University of Basel; and Department of Neurology (U.F.), University Hospital Bern, University of Bern, Switzerland.

Published: February 2023

Current guidelines lack specific recommendations for mechanical thrombectomy (MT) in patients with preexisting disability who present with large vessel occlusion (LVO) more than 6 hours after their last known well time.
A study analyzed 554 patients treated in a 6- to 24-hour window, finding that those who received MT had significantly higher odds of returning to their baseline level of function compared to those treated with medical management.
Key factors affecting recovery included premorbid disability, with those having a higher baseline mRS showing better odds of recovery, while higher stroke severity scores and lower brain imaging scores negatively impacted outcomes.

Background And Objectives: Current guidelines do not address recommendations for mechanical thrombectomy (MT) in the extended time window (>6 hours after time last seen well [TLSW]) for large vessel occlusion (LVO) patients with preexisting modified Rankin Scale (mRS) > 1. In this study, we evaluated the outcomes of MT vs medical management in patients with prestroke disability presenting in the 6- to 24-hour time window with acute LVO.

Methods: We analyzed a multinational cohort (61 sites, 6 countries from 2014 to 2020) of patients with prestroke (or baseline) mRS 2 to 4 and anterior circulation LVO treated 6-24 hours from TLSW. Patients treated in the extended time window with MT vs medical management were compared using multivariable logistic regression and inverse probability of treatment weighting (IPTW). The primary outcome was the return of Rankin (ROR, return to prestroke mRS by 90 days).

Results: Of 554 included patients (448 who underwent MT), the median age was 82 years (interquartile range [IQR] 72-87) and the National Institutes of Health Stroke Scale (NIHSS) was 18 (IQR 13-22). In both MV logistic regression and IPTW analysis, MT was associated with higher odds of ROR (adjusted OR [aOR] 3.96, 95% CI 1.78-8.79 and OR 3.10, 95% CI 1.20-7.98, respectively). Among other factors, premorbid mRS 4 was associated with higher odds of ROR (aOR, 3.68, 95% CI 1.97-6.87), while increasing NIHSS (aOR 0.90, 95% CI 0.86-0.94) and decreasing Alberta Stroke Program Early Computed Tomography Scale score (aOR per point 0.86, 95% CI 0.75-0.99) were associated with lower odds of ROR. Age, intravenous thrombolysis, and occlusion location were not associated with ROR.

Discussion: In patients with preexisting disability presenting in the 6- to 24-hour time window, MT is associated with a higher probability of returning to baseline function compared with medical management.

Classification Of Evidence: This investigation's results provide Class III evidence that in patients with preexisting disability presenting 6-24 hours from the TLSW and acute anterior LVO stroke, there may be a benefit of MT over medical management in returning to baseline function.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9969918	PMC
http://dx.doi.org/10.1212/WNL.0000000000201543	DOI Listing

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