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 - 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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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 -