J Cerebrovasc Endovasc Neurosurg.  2021 Dec;23(4):354-358. 10.7461/jcen.2021.E2021.01.003.

Extending the stroke treatment window beyond DAWN in patients with very slow progressor type collaterals: How far can we go?

• Pagiola I
• Chassin O
• Gallas S
• Riviere MS
• Legris N
• Mihalea C
• Caroff J
• Ikka L
• Chalumeau V
• Aguiar GBd
• Ozanne A
• Moret J
• Denier C
• Spelle L

• KMID: 2523894
• DOI: http://doi.org/10.7461/jcen.2021.E2021.01.003

Abstract

Five trials published in 2015 showed the benefit of endovascular thrombectomy (ET) in patients with stroke and large vessel occlusion, extending the treatment window has become an obsession of all physicians. In 2018, the DAWN and DEFUSE-3 trials showed that, with careful selection of patients, the procedure could be carried out up to 24 hours after symptom onset with good outcomes. In addition, there have been cases where the DAWN criteria were met, and treatment occurred >24 hours after symptom onset. We present the case of a 68-year-old female whose groin puncture occurred 52 hours after the time last known well (TLKW), after neurological worsening of the initial situation, with a large mismatch ratio observed on magnetic resonance imaging, achieving TICI (the Thrombolysis in Cerebral Infarction scale) grade 3 recanalization. Five days after the procedure, the patient was discharged with NIHSS (National Institutes of Health Stroke Scale) score of 3. Some types of collateral circulation (slow progressors and “turtle” progressors, our term for very slow progressors) can extend the treatment window beyond 24 hours of the TLKW but can lead to a hyperperfusion-like syndrome immediately after the ET. Further studies are needed to evaluate the reproducibility of this hypothetical syndrome.

Keyword

Cerebral blood flow, Collateral circulation, Stroke, Mechanical thrombectomy, Large vessel occlusion, Endovascular treatment

Figure

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  Fig. 1. Cranial CT angiography showing a left M1 occlusion (yellow arrow in A and B) with good collateral circulation to the left cerebral hemisphere (C). A–coronal view; B and C–axial view. CT, computed tomography.

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  Fig. 2. MRI and perfusion MRI at 51 hours after TLKW and endovascular thrombectomy 52 hours after TLKW. MRI before endovascular treatment DWI (A), FLAIR (B) and perfusion (C), Left ICA DSA image before mechanical thrombectomy Anteriorposterior (D), and after one pass of ADAPT (E). MRI, magnetic resonance imaging; TLKW, time last known well; DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery; ICA, internal carotid artery; DSA, digital subtraction angiography; ADAPT, a direct-aspiration first-pass technique.

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