J Stroke.  2023 Sep;25(3):378-387. 10.5853/jos.2023.00759.

Clinical and Safety Outcomes of Endovascular Therapy 6 to 24 Hours After Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

• Galecio-Castillo M
• Farooqui M
• Hassan AE
• Jumaa MA
• Divani AA
• Ribo M
• Abraham M
• Petersen NH
• Fifi JT
• Guerrero WR
• Malik AM
• Siegler JE
• Nguyen TN
• Sheth S
• Yoo AJ
• Linares G
• Janjua N
• Quispe-Orozco D
• Tekle W
• Zaidi SF
• Sabbagh SY
• Olivé-Gadea M
• Barkley T
• Leacy RD
• Sprankle KW
• Abdalkader M
• Salazar-Marioni S
• Soomro J
• Gordon W
• Turabova C
• Vivanco-Suarez J
• Rodriguez-Calienes A
• Mokin M
• Yavagal DR
• Jovin T
• Ortega-Gutierrez S

• KMID: 2546439
• DOI: http://doi.org/10.5853/jos.2023.00759

Abstract

Background and Purpose
Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6–24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6–24 hours.
Methods
This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (<6 hours), and late window (6–24 hours). Primary clinical and safety outcomes were 90-day functional independence measured by the modified Rankin Scale (mRS: 0–2) and symptomatic intracranial hemorrhage (sICH). Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), first-pass effect, early neurological improvement, ordinal mRS, and in-hospital and 90-day mortality.
Results
Of 579 patients (median age 68, 32.1% females), 268 (46.3%) were treated in the late window and 311 (53.7%) in the early window. Late window group had lower median National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early Computed Tomography Score, rates of intravenous thrombolysis, and higher rates for perfusion imaging. After adjusting for confounders, the odds of 90-day mRS 0–2 (47.7% vs. 45.0%, adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.49–1.02), favorable shift in mRS (aOR 0.88, 95% CI 0.44–1.76), and sICH (3.7% vs. 5.2%, aOR 0.56, 95% CI 0.20–1.56) were similar in both groups. There was no difference in secondary outcomes. Increased time from LKW to puncture did not predicted the probability of 90-day mRS 0–2 (aOR 0.99, 95% CI 0.96–1.01, for each hour delay) among patients presenting <24 hours.
Conclusion
EVT for acute TL-LVO treated within 6–24 hours after LKW was associated with similar rates of clinical and safety outcomes, compared to patients treated within 6 hours.

Keyword

Ischemic stroke; Carotid artery diseases; Tandem lesions; Thrombectomy; Early window; Late window

Figure

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  Figure 1. Flow diagram of patients included in the study. ICA, internal carotid artery; LKW, last know well.

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  Figure 2. Bar charts of (A) shift analysis of modified Rankin Scale (mRS) at 90 days and (B) predicted probability of mRS 0–2 at 90 days. aOR, adjusted odds ratio; OR, odds ratio; CI, confidence interval; CAD, coronary artery disease; NIHSS, National Institutes of Health Stroke Scale; IV-tPA, intravenous tissue plasminogen activator; mTICI, modified Thrombolysis in Cerebral Infarction; sICH, symptomatic intracranial hemorrhage; ICA, internal carotid artery; ASPECTS, Alberta Stroke Program Early Computed Tomography Score; mRS, modified Rankin Scale; DTAS, direct to angiosuite strategy. *Proportional odds model: adjusted for age, sex, CAD, initial NIHSS, IV-tPA, mTICI 2b-3, sICH, ICA treatment timing, and ASPECTS; †Binomial model (mRS 0–2 vs. 3–6): adjusted for age, sex, CAD, initial NIHSS, IV-tPA, DTAS strategy, mTICI 2b-3, sICH, ICA stenting, pre-procedure ICA stenosis, first pass effect, and ASPECTS.

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  Figure 3. Bar chart of rates of symptomatic ICH, PH2, and petechial hemorrhage in TLs treated in the early window and late window. ICH, intracranial hemorrhage; PH2, parenchymal hematoma type 2; TLs, tandem lesions; IV, intravenous; ASPECTS, Alberta Stroke Program Early Computed Tomography Score; ICA, internal carotid artery; OR, odds ratio; aOR, adjusted odds ratio. *Adjusted for sex, hypertension, diabetes mellitus, atrial fibrillation, direct to angiosuite strategy, IV heparin, periprocedural antiplatelets regimens, and first pass effect; †Adjusted for diabetes mellitus, atrial fibrillation, direct to angiosuite strategy, ASPECTS, IV heparin, periprocedural antiplatelets regimens, and first pass effect; ‡Adjusted for race, atrial fibrillation, ASPECTS, IV heparin, and ICA stenting.

Reference

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