Association Between Time to Treatment and Outcomes of Endovascular Therapy vs Medical Management in Patients With Large Ischemic Stroke.

Neurology

From the Department of Emergency (G.Y., Lei Liu, H.X., J.W., C.L., J.X., F.H., B.H., D.W., H.W., C.F., Y.L., X.Z., W.Y., Z.H., Y.X., Libo Lei), Xiangtan Central Hospital (The Affiliated Hospital of Hunan University); Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Westlake University School of Medicine, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Cerebrovascular Disease Department (X.H.), Beijing Anzhen Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.H., Y.P., M.W., Z.M.), Beijing; Interventional Neuroradiology (Y.P., M.W., Z.M.), Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; Department of Neurology (Z.Q.), The 903rd Hospital of the People's Liberation Army, Hangzhou, China; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA, Los Angeles, CA; and Department of Neurology (X.C.), the Central Hospital of Lishui, the Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China.

Published: January 2025

Background And Objectives: Randomized trials have proven the benefit of endovascular therapy (EVT) for acute large ischemic stroke. This study was to characterize the effect of time to treatment on benefit of EVT vs medical management (MM) among patients with large ischemic stroke.

Methods: This was a post hoc analysis of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core randomized trial. Patients who had an Alberta Stroke Program Early Computed Tomography Score of 3-5 or an ischemic core volume of 70-100 mL within 24 hours of symptom onset were treated with EVT plus MM or MM. Onset-to-expected arterial puncture time (OPT) was analyzed as a categorical variable (<6, 6-<12, and 12-24 hours) using binary logistic regression and as a continuous variable using a multivariable fractional polynomial interaction. The primary efficacy outcome was favorable outcomes (modified Rankin Scale scores 0-3) at 90 days. Safety outcomes included any intracranial hemorrhage (ICH), symptomatic ICH, and mortality.

Results: Among 451 patients (median age 68 years; 61.4% were men; median OPT 487 minutes [interquartile range 328-802]), 226 patients received EVT and 225 patients received MM. The EVT group showed higher rates of favorable outcomes than the MM group within OPT of 6 hours (44.4% vs 29.9%, adjusted odds ratio [aOR] 2.78, 95% CI 1.22-6.32) and 6-12 hours (45.7% vs 29.6%, aOR 2.39 [95% CI 1.21-4.71]), but not in OPT beyond 12 hours (51.6% vs 41.4%, aOR 2.05 [95% CI 0.88-4.77]). The benefit became nonsignificant after OPT of 13 hours and 22 minutes. In 3 OPT intervals, the rates of symptomatic ICH and mortality were similar between EVT and MM although the rate of any ICH increased. However, no interaction effect was found (all interactions >0.10).

Discussion: These findings strengthen the benefit of EVT initiated within 13 hours and 22 minutes after symptom onset compared with MM alone in patients with large ischemic stroke, but EVT should not be withheld for patients presenting beyond 13 hours and 22 minutes. Pooled analysis of larger sample sizes is needed.

Trial Registration Information: ClinicalTrials.gov; NCT04551664.

Classification Of Evidence: This study provides Class II evidence that EVT is associated with improved functional outcomes for acute large ischemic stroke within 24 hours after last known well, with no interaction by time.

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http://dx.doi.org/10.1212/WNL.0000000000210133DOI Listing

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