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Dhillon PS, Butt W, Podlasek A, McConachie N, Lenthall R, Nair S, Malik L, Bhogal P, Makalanda HLD, Spooner O, Krishnan K, Sprigg N, Mortimer A, Booth TC, Lobotesis K, White P, James MA, Bath P, Dineen RA, England TJ. Association between time to treatment and clinical outcomes in endovascular thrombectomy beyond 6 hours without advanced imaging selection. J Neurointerv Surg 2023; 15:336-342. [PMID: 35296526 DOI: 10.1136/neurintsurg-2021-018564] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/24/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The effectiveness and safety of endovascular thrombectomy (EVT) in the late window (6-24 hours) for acute ischemic stroke (AIS) patients selected without advanced imaging is undetermined. We aimed to assess clinical outcomes and the relationship with time-to-EVT treatment beyond 6 hours of stroke onset without advanced neuroimaging. METHODS Patients who underwent EVT selected with non-contrast CT/CT angiography (without CT perfusion or MR imaging), between October 2015 and March 2020, were included from a national stroke registry. Functional and safety outcomes were assessed in both early (<6 hours) and late windows with time analyzed as a continuous variable. RESULTS Among 3278 patients, 2610 (79.6%) and 668 (20.4%) patients were included in the early and late windows, respectively. In the late window, for every hour delay, there was no significant association with shift towards poorer functional outcome (modified Rankin Scale (mRS)) at discharge (adjusted common OR 0.98, 95% CI 0.94 to 1.01, p=0.27) or change in predicted functional independence (mRS ≤2) (24.5% to 23.3% from 6 to 24 hours; aOR 0.99, 95% CI0.94 to 1.04, p=0.85). In contrast, predicted functional independence was time sensitive in the early window: 5.2% reduction per-hour delay (49.4% to 23.5% from 1 to 6 hours, p=0.0001). There were similar rates of symptomatic intracranial hemorrhage (sICH) (3.4% vs 4.6%, p=0.54) and in-hospital mortality (12.9% vs 14.6%, p=0.33) in the early and late windows, respectively, without a significant association with time. CONCLUSION In this real-world study, there was minimal change in functional disability, sICH and in-hospital mortality within and across the late window. While confirmatory randomized trials are needed, these findings suggest that EVT remains feasible and safe when performed in AIS patients selected without advanced neuroimaging between 6-24 hours from stroke onset.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK .,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Anna Podlasek
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Pervinder Bhogal
- Interventional Neuroradiology, The Royal London Hospital Barts Health NHS Trust, London, UK
| | | | - Oliver Spooner
- Stroke Medicine, The Royal London Hospital Barts Health NHS Trust, London, UK
| | - Kailash Krishnan
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alex Mortimer
- Interventional Neuroradiology, Southmead Hospital North Bristol NHS Trust, Bristol, Bristol, UK
| | - Thomas Calvert Booth
- Department of Neuroradiology, King's College Hospital NHS Foundation Trust, London, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, London, UK
| | - Philip White
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Martin A James
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Sentinel Stroke National Audit Programme, King's College London, London, UK
| | - Philip Bath
- Stroke Medicine, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK.,Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Robert A Dineen
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Strokes Trial Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Mental Health and Clinical Neuroscience, School of Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Ren Z, Ma G, Mokin M, Jadhav AP, Jia B, Tong X, Bauer C, Liu R, Wang A, Zhang X, Mo D, Ma N, Gao F, Song L, Sun X, Huo X, Deng Y, Liu L, Luo G, Luo X, Peng Y, Gui L, Song C, Wu J, Wang L, Li C, Jovin TG, Wang Y, Wang Y, Miao Z. Non-contrast head CT alone for thrombectomy in acute ischemic stroke: analysis of the ANGEL-ACT registry. J Neurointerv Surg 2021; 14:868-874. [PMID: 34599086 DOI: 10.1136/neurintsurg-2021-017940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/25/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUD The goal of this study was to determine if the choice of imaging paradigm performed in the emergency department influences the procedural or clinical outcomes after mechanical thrombectomy (MT). METHODS This is a retrospective comparative outcome study which was conducted from the ANGEL-ACT registry. Comparisons were made between baseline characteristics and clinical outcomes of patients with acute ischemic stroke undergoing MT with non-contrast head computed tomography (NCHCT) alone versus patients undergoing NCHCT plus non-invasive vessel imaging (NVI) (including CT angiography (with or without CT perfusion) and magnetic resonance angiography). The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included change in mRS score from baseline to 90 days, the proportions of mRS 0-1, 0-2, and 0-3, and dramatic clinical improvement at 24 hours. The safety outcomes were any intracranial hemorrhage (ICH), symptomatic ICH, and mortality within 90 days. RESULTS A total of 894 patients met the inclusion criteria; 476 (53%) underwent NCHCT alone and 418 (47%) underwent NCHCT + NVI. In the NCHCT alone group, the door-to-reperfusion time was shorter by 47 min compared with the NCHCT + NVI group (219 vs 266 min, P<0.001). Patients in the NCHCT alone group showed a smaller increase in baseline mRS score at 90 days (median 3 vs 2 points; P=0.004) after adjustment. There were no significant differences between groups in the remaining clinical outcomes. CONCLUSIONS In patients selected for MT using NCHCT alone versus NCHCT + NVI, there were improved procedural outcomes and smaller increases in baseline mRS scores at 90 days.
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Affiliation(s)
- Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | | | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Clayton Bauer
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Raynald Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuelei Zhang
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ya Peng
- Neurosurgery, The First People's Hospital of Changzhou,The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Liqiang Gui
- Interventional Neuroradiology, Langfang Changzheng Hospital, Langfang, Hebei, China
| | - Cunfeng Song
- Department of Interventional Neuroradiology, The Third People's Hospital of Liaocheng City, Liaocheng, China
| | - Jin Wu
- Neurology, Nanjing Medical University Second Affiliated Hospital, Nanjing, Jiangsu, China
| | - Leyuan Wang
- Interventional Neuroradiology Center, Changle People's Hospital, Weifang, China
| | - Chunlei Li
- Department of Neurology, The Second People's Hospital of Dongying City, Dongying, China
| | - Tudor G Jovin
- Cooper Neurologic Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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