Neurointervention.  2017 Sep;12(2):59-68. 10.5469/neuroint.2017.12.2.59.

A Meta-Analysis of Observational Evidence for the Use of Endovascular Thrombectomy in Proximal Occlusive Stroke Beyond 6 Hours in Patients with Limited Core Infarct

• Wareham J
• Phan K
• Renowden S
• Mortimer A

• KMID: 2389497
• DOI: http://doi.org/10.5469/neuroint.2017.12.2.59

Abstract

PURPOSE
The safety and efficacy of endovascular thrombectomy (EVT) for patients with proximal occlusive stroke presenting beyond 6 hours and selected on the basis of favorable neuroimaging remains unclear.
MATERIALS AND METHODS
A systematic search was performed from four electronic databases from their inception to Jan 2017. A meta-analysis of outcomes from studies with patients treated beyond 6 hours was compared to those treated within the established 6 hour therapeutic window in randomized trials, selected using conventional imaging methods with CT/CT angiography.
RESULTS
A total of 8 articles met inclusion criteria for the study population (a prospective single-center study, 5 retrospective single-center studies and 2 retrospective multicenter studies). These were compared to the results of three prospective trials of patients treated within 6 hours selected using CT/CT angiography. For patients treated >6 hours and <6 hours respectively, the weighted mean age was 64.7 vs. 67.0 years; the presenting NIHSS was 15.7 vs. 17.1 and the time from symptom onset to puncture was 4.0 hours vs. 15.1 hours. Weighted pooled estimates of successful recanalization (TIMI 2/3 or TICI 2b/3) and favorable outcome (mRS ≤2) were similar between both groups, 70.1% vs. 70.6%, P=0.75 and 38.9% vs. 38.4%, P=0.88 respectively. Pooled mortality measured at 3 months was 22.8% for those treated >6 hours and 12.5% for <6 hours, P<0.0001. Symptomatic intracranial hemorrhage was not significantly different (10.0% vs. 7.7%, P=0.33).
CONCLUSION
When compared to established methods of patient selection, EVT employed beyond 6 hours in those selected with imaging to exclude large core infarcts achieves similar rates of recanalization, and functional outcome but there is a significant increase in mortality despite no increase in symptomatic intracranial hemorrhage.

Keyword

Stroke; Thrombectomy; Endovascular; Perfusion; Infarct

MeSH Terms

Angiography
Humans
Intracranial Hemorrhages
Mortality
Neuroimaging
Patient Selection
Perfusion
Prospective Studies
Punctures
Retrospective Studies
Stroke*
Thrombectomy*

Figure

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  Fig. 1 Forest plot for recanalisation (TIMI 2/3 or TICI 2b/3).

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  Fig. 2 Forest plot for symptomatic intracranial haemorrhage.

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  Fig. 3 Forest plot for favorable outcome (mRS≤2).

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  Fig. 4 Forest plot for 90 day mortality.

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