Predictors of functional outcome following acute ischemic stroke secondary to M1 MCA/ICA occlusion in the extended time window

Predictors of functional outcome following acute ischemic stroke secondary to M1 MCA/ICA occlusion in the extended time window | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Predictors of functional outcome following acute ischemic stroke secondary to M1 MCA/ICA occlusion in the extended time window View ORCID Profile John Constantakis , Quinn Steiner , Thomas Reher , Timothy Choi , Fauzia Holangel , Qianqian Zhao , Nicole Bennett , View ORCID Profile Veena A. Nair , View ORCID Profile Eric Adelman , Vivek Prabhakaran , Beverly Aagard-Kienitz , Bolanle Famakin doi: https://doi.org/10.1101/2024.11.05.24316799 John Constantakis 1 Berbee Walsh Department of Emergency Medicine, University of Wisconsin Hospitals and Clinics , Madison, WI DO Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for John Constantakis Quinn Steiner 2 University of Wisconsin School of Medicine and Public Health , Madison, WI MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Thomas Reher 3 Monument Health Rapid City Hospital , Rapid City, SD 57701 MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Timothy Choi 4 Department of Radiology, UW Health University Hospital , 600 Highland Ave, Madison, WI 53792 MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Fauzia Holangel 5 Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health , Madison, WI MPH Find this author on Google Scholar Find this author on PubMed Search for this author on this site Qianqian Zhao 6 Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health , Madison, WI 53726 MS Find this author on Google Scholar Find this author on PubMed Search for this author on this site Nicole Bennett 7 University of Wisconsin Hospitals and clinics , 600 Highland Ave, Madison, WI 53792 MS, RN Find this author on Google Scholar Find this author on PubMed Search for this author on this site Veena A. Nair 4 Department of Radiology, UW Health University Hospital , 600 Highland Ave, Madison, WI 53792 PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Veena A. Nair Eric Adelman 8 Department of Neurology, University of Wisconsin School of Medicine and Public Health, Medical Foundation Centennial Building , 1685 Highland Ave, Madison, WI 53705 MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Eric Adelman Vivek Prabhakaran 4 Department of Radiology, UW Health University Hospital , 600 Highland Ave, Madison, WI 53792 MD, PhD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Beverly Aagard-Kienitz 4 Department of Radiology, UW Health University Hospital , 600 Highland Ave, Madison, WI 53792 MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site Bolanle Famakin 8 Department of Neurology, University of Wisconsin School of Medicine and Public Health, Medical Foundation Centennial Building , 1685 Highland Ave, Madison, WI 53705 MD Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: famakin{at}wisc.edu Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Introduction A validated clinical decision tool predictive of favorable functional outcomes following endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) remains elusive. We performed a retrospective case series of patients at our regional Comprehensive Stroke Center, over a 4-year period, who have undergone EVT to elucidate patient characteristics and factors associated with a favorable functional outcome after EVT. Methods We reviewed all cases of EVT at our institution from 2/2018 - 2/2022 in the extended time window from 6 – 24 hours. Demographic, clinical, imaging, and procedure co-variates were included. A favorable clinical outcome was defined as a modified Rankin scale or 0-2. We included patients with M1 or ICA occlusion treated with EVT within 6-24 hours after symptom onset. We used a univariate and multivariate logistic regression analysis to identify patient factors associated with a favorable clinical outcome at 90 days. Results Our analysis demonstrates that higher recanalization score based on the mTICI scale (2B-3) was a strong indicator of favorable outcome per both our multivariate and univariate analysis (OR 4.11; CI 1.10 – 15.31; p 0.035). Our data also showed signal that the younger age ( p 0.013), lower baseline NIHSS ( p 0.043), shorter hospital length of stay (LOS) ( p 0.030), and absence of pre-existing hypertension ( p 0.026) may also be a predictor of favorable outcome per our univariate analysis. Conclusion Patients without pre-existing hypertension had more favorable outcomes following EVT in the expanded time window. This is consistent with other multicenter data in the expanded time window that demonstrates greater odds of a poor outcome with elevated pre-, peri-, and post-endovascular treatment blood pressure. Our data also demonstrates mTICI score is a strong predictor of favorable outcome even when controlled for other variables. Other factors that may indicate a favorable outcome include younger age, lower baseline NIHSS, and shorter hospital LOS. Introduction Ischemic stroke incidence, prevalence, and mortality are increasing annually with this trend expected to continue 1 . Endovascular intervention for stroke has emerged as an effective treatment strategy in patients with an acute ischemic stroke secondary to large vessel occlusion (LVO) 2 . Initially, significant clinical benefit was seen when endovascular intervention was performed within 6 hours after the onset of stroke symptoms 3 , 4 . However, the recent DEFUSE-3 and DAWN trials expanded this time window out to 6-24 hours 5 , 6 . Although the guidelines for the acute treatment of stroke have evolved to include this expanded time window from 6-24 hours; even according to our study, there are large variations in patient outcomes. Within this expanded time window, 40-50% of patients have poor neurological outcomes per modified Rankin scores (mRS) (defined as mRS 3-6), with mortality rates around 15% 5 - 8 . A variety of factors have been identified as correlating with worse clinical outcomes following stroke 9 , 10 ; however, a clinically usable model for outcome prognostication has remained elusive. We sought to examine our single center experience at a major, regional, comprehensive stroke center with endovascular intervention for acute ischemic stroke in patients with M1 MCA and ICA occlusions. Patients with these types of LVOs typically have a worse prognosis 5 , 6 . These LVOs constitute many patients that undergo endovascular intervention 5 , 6 . Consequently, understanding factors that impact outcomes may greatly improve quality of care. The purpose of our investigation is to identify potential clinical and imaging biomarkers predictive of a favorable functional outcome following acute stroke secondary to M1 and ICA occlusion during the extended time window. This would ideally be used to predict pre-procedurally which patients would show the greatest functional outcome response to thrombectomy. Methods Patient Selection After approval from our institutional review board, we retrospectively reviewed all patients admitted or transferred to our hospital who underwent endovascular stroke treatment for arterial ischemic stroke from 6 – 24 hours after symptom onset between 2/2018 - 2/2022. The decision to perform the endovascular procedure was made on an individual basis with consensus between the neuro-interventionalist and neurology team. We included patients older than 18 years who underwent endovascular intervention for occlusion of M1 vessels as well as either intracranial or cervical ICA vessels and had baseline imaging performed at University of Wisconsin University Hospital, had a time from symptoms onset of greater than 6 but less than 24 hours. All procedures were performed using standard of care guidelines 5 , 6 . We collected patient baseline clinical and radiological characteristics, procedure details, and outcomes such as the degree of successful recanalization according to the modified Thrombolysis In Cerebral Infarction [mTICI] scale (grade of 0-3, with higher scores indicating greater recanalization). Specifically, a grade is assigned at the end of the procedure-[mTICI 2b and less indicating lesser recanalization, and rates of complete/near-complete recanalization defined as [mTICI 3, mTICI 2c]. We defined a favorable outcome as an mRS score of 0-2 at 90-days post presentation 11 . We also compared whether each patient taken for thrombectomy met criteria as outlined by the DAWN and DEFUSE-3 trials in terms of clinical or radiographic mismatch. Statistical Methodology Outcome Analyses To assess the predictors of a patient encountering an unfavorable outcome, we conducted a univariate and multivariate logistic regression model and reported odds ratios and 95% confidence intervals. Significant predictors from the univariate model were adjusted for in the multivariate analyses. We graphically examined differences in the outcome using coefficient plots with extended confidence widths. We checked for multicollinear variables using a variance inflation factor (VIF). Any variable with a VIF values ≥10 was excluded from the multivariate analyses. We corrected for missing data using pairwise deletion for categorical data or multiple imputation methods for continuous variables. Variables with greater than 50% missing data were removed from the analysis altogether. All p-values less than 0.05 were considered significant. All statistical analyses were completed with the use of SAS Version 9.4 (Cary, NC) and STATA version 17. Descriptive Analyses We summarized demographic and outcome measures using raw counts and frequencies for all categorical, binary, and ordinal variables. Comparisons between favorable outcome groups were made using chi-square tests or Fisher’s exact tests for cells less than 5. Continuous variables were expressed as mean plus standard deviation (SD) or median plus interquartile range (IQR) for non-normal data. Continuous variable comparisons were made using a student t-test or the non-parametric Wilcoxon rank sum test for non-normal distributions. Results A total of 679 patients underwent thrombectomy at our comprehensive stroke center over a 4-year period. Of these, 121 (18%) met inclusion criteria (CT or MR perfusion on arrival, carotid or M1 occlusion) ( Figure 1 ), and satisfactory data complements were found in 54 of these 121 (45%)-meaning the variable contained >50% of the investigated data fields. Download figure Open in new tab Figure 1: Patient Flow Chart Patient Cohort Characteristics and Outcomes Baseline characteristics are outlined in Table 1 . The groups did not differ significantly in occlusion site, sex, or smoking history. The groups also did not differ significantly in whether they had a diagnosis of diabetes, atrial fibrillation, decreased cardiac ejection fraction (EF), or cervical carotid involvement. Favorable clinical outcomes were observed in 55 (44%) patients, 15 (18%) of which had ICA occlusions and 45 (82%) of which had M1 occlusions. Patients with favorable outcomes had a younger age, lower baseline NIHSS, a shorter length of stay, and higher TICI score. View this table: View inline View popup Table 1: Baseline characteristics and medical history of cohort This table presents baseline characteristics and medical history of a cohort, categorized by favorable (MRS 0-2) and unfavorable (MRS 3-6) outcomes, with an overall grouping of MRS 0-6. Predictors of Favorable Outcomes Based on the logistic regression analysis, several factors were examined to determine their association with favorable outcomes in the studied cohort. Age, Length of stay (LOS), and NIHSS were associated with favorable outcome in univariate analyses but were not significant predictors in the multivariable model. Ejection fraction (EF) did not demonstrate a significant association with favorable outcomes in either univariate or multivariate analyses, suggesting that it may not be a strong predictor of favorable outcomes in this cohort. In summary, timely reperfusion therapy and discharge to home emerged as strong predictors of favorable outcomes, underscoring the importance of these interventions in improving outcomes for stroke patients. Although hypertension initially showed a significant association with favorable outcomes in the univariate analysis, this association became non-significant after adjusting for other variables, indicating that hypertension alone may not independently predict favorable outcomes. Other factors, such as age, LOS, stroke severity, hypertension, and EF, may not independently predict favorable outcomes once other variables are considered ( Table 2 ). View this table: View inline View popup Table 2: Predictors of favorable outcome (MRS 0 - 2) Logistic regression table presents predictors of a favorable outcome (MRS 0-2) after analyzing associated variables in both a univariate and multivariate analysis. Notably, achieving higher levels of reperfusion (as indicated by a TICI score of 2B-3) emerged as a strong predictor of favorable outcomes, maintaining its significance in both univariate and multivariate analyses. Moreover, various discharge dispositions, particularly being discharged to home, were significantly associated with favorable outcomes in both univariate and multivariate analyses. Discussion These data represent a single center, retrospective analysis that sought to identify clinical and imaging factors that could be utilized as prognostic indicators of favorable outcomes of endovascular stroke treatment in patients presenting with a proximal ICA/M1 MCA occlusion in the expanded thrombectomy time window. We acknowledge the limitations of our study-including our retrospective and single center design. Our single center model and low sample size was limiting in terms of statistical power for some analyses. Our data mirrored findings of the DEFUSE-3 and DAWN study ( Figure 2 ), demonstrating that later time from symptom onset to arterial groin puncture (>12 hours) was associated with a better odds ratio (OR 1.001; p-value 0.019) of an improved functional outcome (mRS 0-2) at 90 days compared with earlier arrival. This contrasts with other data suggesting that last known normal (LKN) to time to groin puncture was a significant prognostic indicator of a favorable outcome 12 , 13 . A potential explanation for this difference is that it may be a less critical factor in patients presenting in the expanded time window. Download figure Open in new tab Figure 2: Forest plot of odds ratio of variables and their association with thrombectomy outcome. Both DAWN and DEFUSE-3 demonstrated larger absolute benefits with later treatments compared with early window thrombectomy RCTs (e.g., HERMES, MR CLEAN, etc). This was later dubbed the “Late Window Paradox” 14 . Proposed explanations for this paradox include-slow growth of the ischemic core in some patients, presence of more robust collateral circulation, and the influence of lack of tPA administration in the medical control groups of the late window trials. It is possible that our population represented one with more robust collateral circulation. This finding countered the popular mantra of “time is brain,” which implied that time to reperfusion was the sole variable important for LVO outcomes. Further, it demonstrated the collective heterogeneity of this patient population and cerebrovasculature. We hypothesize that presence of robust collateral circulation and delayed growth of the ischemic core have a significant influence on overall prognosis following endovascular stroke therapy. This implies that the degree of mismatch is the more important factor in patient selection for endovascular stroke treatment. The AURORA study 15 , which was a pooled analysis of six RCTs (including DAWN and DEFUSE-3)-sought to answer the question regarding is there an advantage to selecting based off clinical mismatch (DAWN criteria), or target perfusion mismatch (DEFUSE-3 criteria). Importantly, it found a similar benefit in terms of functional independence (mRS 0-2) at 90 days regardless of which mismatch criteria was chosen. This finding was reflected in our data set that showed no statistical impact on outcome whether DAWN or DEFUSE-3 criteria were used. Further research is investigating to what degree of mismatch is necessary for functional benefit to be achieved-but recent studies are demonstrating that benefit is possible beyond the mismatch criteria defined in the DAWN and DEFUSE-3 studies. Recently published RCTs, the SELECT-2 16 and RESCUE-JAPAN LIMIT 17 have demonstrated that patients with a low ASPECTs score (which is generally considered to correlate to the area of core infarct) have greater odds of achieving functional independence with MT compared with undergoing medical therapy alone. Both RCTs along with other observational studies and meta-analyses have already demonstrated the benefit of endovascular stroke treatment despite a low ASPECTs score (defined as ASPECTs 2-5) 18 , 7 . This is consistent with our data that showed no statistically significant association with ASPECTs score and a favorable endovascular stroke treatment outcome. Further, this also suggests that the degree of recanalization, as demonstrated by the post-procedural mTICI score is also the more critical indicator of prognosis which has also been shown in the literature. 19 A significant negative association that our data reflected was that the presence of hypertension (defined as a prior to admission, SBP > 140) was less likely to lead to a favorable outcome (OR 0.32; p-value 0.009; 95% CI 0.12-0.75). This is also consistent with other multicenter data that demonstrates greater odds of a poor outcome with elevated pre-, peri-, and post-endovascular treatment blood pressure 20 . Possible explanations identified include an increased risk of symptomatic intracerebral hemorrhage (sICH) and reduced rates of successful recanalization. Our data also demonstrated that the presence of symptomatic post-endovascular treatment ICH was more likely to be associated with a less favorable outcome and higher post-procedure mRS. This is consistent with other investigations that have demonstrated an association between hypertension and post-endovascular treatment sICH. However, the causality association was not investigated in our data, whether patients with pre-existing hypertension are more likely to have sICH is still an open question. This is an area of interest to be examined in future analyses. The greater driving factor of this negative association may be more related to decreased odds of successful recanalization. A strong association between hypertension and increased vessel tortuosity is well established and could result in reduced ability to pass an angiocatheter to the site of occlusion and overall success of endovascular stroke treatment 21 . Another interesting hypothesis suggests that uncontrolled HTN may be inversely associated with the development of collateral flow. This would result in a greater hemodynamic force imparted on the area of occlusion and could potentially cause clot impaction and impaired ability for mechanical clot retrieval 22 . Findings we expected demonstrated by our data include-younger age (p-value 0.007), shorter length of stay (p-value 0.003), and lower baseline NIHSS on presentation (p-value 0.021) had greater odds of a favorable outcome. Negative associations demonstrated included discharge to hospice was more likely to be associated with a poor functional outcome (mRS >0-2, p-value 0.001). This likely reflects that patients with a favorable functional outcome are more likely to be discharged home compared to hospice or rehab. Overall, these data add to a growing body of literature that works to refine criteria for patient selection for endovascular stroke treatment in the expanded thrombectomy time window. Data Availability All data underlying the results are available as part of the article. No additional source data is required. Raw data used in analysis is available upon request. Sources of Funding This work was supported by start-up funds, to B.F, from the University of Wisconsin School of Medicine and Public Health, and the department of Neurology University of Wisconsin, School of Medicine and Public Health, Madison, WI. Disclosures The authors have nothing to disclose. Author Contributions JC contributed to chart review, data acquisition, analysis, and authorship of the manuscript. QS contributed to chart review, data acquisition, analysis, and authorship of the manuscript. TR and TC contributed to data acquisition and drafting of methods. FH contributed data analysis and authorship of results. NB contributed to chart review, data acquisition, and drafting of methods. VN contributed to data analysis. VP contributed to study design, data acquisition, and clinical expertise. BAK contributed to study design, acquisition of clinical data, and clinical expertise. EA contributed to authorship and critical review of the manuscript. BF contributed to study conception, design, acquisition of clinical data, and clinical expertise. All authors of this study contributed to authorship and revision of the final manuscript. Author Contributions JC contributed to chart review, data acquisition, analysis, and authorship of the manuscript. QS contributed to chart review, data acquisition, analysis, and authorship of the manuscript. TR and TC contributed to data acquisition and drafting of methods. FH contributed data analysis and authorship of results. NB contributed to chart review, data acquisition, and drafting of methods. EA critically reviewed and revised the manuscript and provided clinical expertise. VN contributed to data analysis. VP contributed to study design, data acquisition, and clinical expertise. BAK contributed to study design, acquisition of clinical data, and clinical expertise. BF contributed to study conception, design, acquisition of clinical data, and clinical expertise. All authors of this study contributed to authorship and revision of the final manuscript. Appendix Acknowledgments, Sources of Funding, & Disclosures Acknowledgments : The authors acknowledge Dr. Eric Adelman, for critically reviewing this manuscript. Footnotes ↵ # Co-first authors References 1. ↵ Feigin VL , Stark BA , Johnson CO , et al. Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019 . Lancet Neurol . 2021 ; 20 ( 10 ): 795 – 820 . doi: 10.1016/S1474-4422(21)00252-0 OpenUrl CrossRef PubMed 2. ↵ Fransen PS , Beumer D , Berkhemer OA , van den Berg LA , Lingsma H , van der Lugt A , van Zwam WH , van Oostenbrugge RJ , Roos YB , Majoie CB , Dippel DW ; MR CLEAN Investigators. MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial . Trials . 2014 Sep 1; 15 : 343 OpenUrl CrossRef PubMed 3. ↵ Powers WJ , Derdeyn CP , Biller J , et al. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment . Stroke . 2015 ; 46 ( 10 ): 3020 – 3035 . OpenUrl Abstract / FREE Full Text 4. ↵ Goyal M , Menon BK , van Zwam WH , et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials . The Lancet . 2016 ; 387 ( 10029 ): 1723 – 1731 . OpenUrl CrossRef 5. ↵ Albers GW , Marks MP , Kemp S , et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging . New England Journal of Medicine . 2018 ; 378 ( 8 ): 708 – 718 . OpenUrl CrossRef PubMed 6. ↵ Nogueira RG , Jadhav AP , Haussen DC , et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct . New England Journal of Medicine . 2018 ; 378 ( 1 ): 11 – 21 . OpenUrl CrossRef PubMed 7. ↵ Almallouhi E , Al Kasab S , Hubbard Z , et al. Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in the Early and Extended Window . JAMA Netw Open . 2021 ; 4 ( 12 ): e2137708 . OpenUrl 8. ↵ Broocks G , Hanning U , Bechstein M , et al. Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction . JAMA Netw Open . 2022 ; 5 ( 10 ): e2235733 . OpenUrl PubMed 9. ↵ O’Connor KP , Hathidara MY , Danala G , et al. Predicting Clinical Outcome After Mechanical Thrombectomy: The GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Sex) Score . World Neurosurg . 2020 ; 134 : e1130 – e1142 . OpenUrl PubMed 10. ↵ Butler J , Heidari P , Blayney S , Hitomi E , Luby M , Leigh R. Blood-brain barrier integrity of stroke patients presenting in an extended time window . BMC Neurol . 2020 ; 20 ( 1 ): 54 . OpenUrl PubMed 11. ↵ van Swieten JC , Koudstaal PJ , Visser MC , Schouten HJ , van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients . Stroke . 1988 May ; 19 ( 5 ): 604 – 7 . OpenUrl Abstract / FREE Full Text 12. ↵ Wang Y , Yuan X , Kang Y , Yu L , Chen W , Fan G. Clinical predictors of prognosis in stroke patients after endovascular therapy . Sci Rep . 2024 Jan 5; 14 ( 1 ): 667 . doi: 10.1038/s41598-024-51356-5 . Erratum in: Sci Rep. 2024 Apr 9;14(1):8282. OpenUrl CrossRef PubMed 13. ↵ Sun CH , Ribo M , Goyal M , Yoo AJ , Jovin T , Cronin CA , Zaidat O , Nogueira R , Nguyen T , Hussain S , Menon BK , Mehta B , Jindal G , Horev A , Norbash A , Leslie-Mazwi T , Wisco D , Gupta R. Door-to-puncture: a practical metric for capturing and enhancing system processes associated with endovascular stroke care, preliminary results from the rapid reperfusion registry . J Am Heart Assoc . 14. ↵ Albers GW . Late Window Paradox . Stroke . 2018 Mar ; 49 ( 3 ): 768 – 771 . OpenUrl FREE Full Text 15. ↵ Jovin TG , Nogueira RG , Lansberg MG , Demchuk AM , Martins SO , Mocco J , Ribo M , Jadhav AP , Ortega-Gutierrez S , Hill MD , Lima FO , Haussen DC , Brown S , Goyal M , Siddiqui AH , Heit JJ , Menon BK , Kemp S , Budzik R , Urra X , Marks MP , Costalat V , Liebeskind DS , Albers GW . Thrombectomy for anterior circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis . Lancet . 2022 Jan 15; 399 ( 10321 ): 249 – 258 . OpenUrl CrossRef PubMed 16. ↵ Sarraj A , Hassan AE , Abraham MG , Ortega-Gutierrez S , Kasner SE , Hussain MS , Chen M , Blackburn S , Sitton CW , Churilov L , Sundararajan S , Hu YC , Herial NA , Jabbour P , Gibson D , Wallace AN , Arenillas JF , Tsai JP , Budzik RF , Hicks WJ , Kozak O , Yan B , Cordato DJ , Manning NW , Parsons MW , Hanel RA , Aghaebrahim AN , Wu TY , Cardona-Portela P , Pérez de la Ossa N , Schaafsma JD , Blasco J , Sangha N , Warach S , Gandhi CD , Kleinig TJ , Sahlein D , Elijovich L , Tekle W , Samaniego EA , Maali L , Abdulrazzak MA , Psychogios MN , Shuaib A , Pujara DK , Shaker F , Johns H , Sharma G , Yogendrakumar V , Ng FC , Rahbar MH , Cai C , Lavori P , Hamilton S , Nguyen T , Fifi JT , Davis S , Wechsler L , Pereira VM , Lansberg MG , Hill MD , Grotta JC , Ribo M , Campbell BC , Albers GW ; SELECT2 Investigators. Trial of Endovascular Thrombectomy for Large Ischemic Strokes . N Engl J Med . 2023 Apr 6; 388 ( 14 ): 1259 – 1271 . OpenUrl CrossRef PubMed 17. ↵ Yoshimura S , Sakai N , Yamagami H , Uchida K , Beppu M , Toyoda K , Matsumaru Y , Matsumoto Y , Kimura K , Takeuchi M , Yazawa Y , Kimura N , Shigeta K , Imamura H , Suzuki I , Enomoto Y , Tokunaga S , Morita K , Sakakibara F , Kinjo N , Saito T , Ishikura R , Inoue M , Morimoto T. Endovascular Therapy for Acute Stroke with a Large Ischemic Region . N Engl J Med . 2022 Apr 7; 386 ( 14 ): 1303 – 1313 . OpenUrl CrossRef PubMed 18. ↵ Mourand I , Abergel E , Mantilla D , Ayrignac X , Sacagiu T , Eker OF , Gascou G , Dargazanli C , Riquelme C , Moynier M , Bonafé A , Arquizan C , Costalat V. Favorable revascularization therapy in patients with ASPECTS ≤ 5 on DWI in anterior circulation stroke . J Neurointerv Surg . 2018 Jan ; 10 ( 1 ): 5 – 9 . OpenUrl Abstract / FREE Full Text 19. ↵ Sarzetto F , Gupta S , Alotaibi NM , Howard P , da Costa L , Heyn C , Maralani PJ , Guha D , Swartz RH , Boyle K , Yang VXD . Outcome Evaluation of Acute Ischemic Stroke Patients Treated with Endovascular Thrombectomy: A Single-Institution Experience in the Era of Randomized Controlled Trials . World Neurosurg . 2017 Mar ; 99 : 593 – 598 . doi: 10.1016/j.wneu.2016.12.054 . OpenUrl CrossRef PubMed 20. ↵ Malhotra K , Goyal N , Katsanos AH , Filippatou A , Mistry EA , Khatri P , Anadani M , Spiotta AM , Sandset EC , Sarraj A , Magoufis G , Krogias C , Tönges L , Safouris A , Elijovich L , Goyal M , Arthur A , Alexandrov AV , Tsivgoulis G. Association of Blood Pressure With Outcomes in Acute Stroke Thrombectomy . Hypertension . 2020 Mar ; 75 ( 3 ): 730 – 739 . OpenUrl CrossRef 21. ↵ Ciurică S , Lopez-Sublet M , Loeys BL , Radhouani I , Natarajan N , Vikkula M , Maas Ahem , Adlam D , Persu A. Arterial Tortuosity . Hypertension . 2019 May ; 73 ( 5 ): 951 – 960 . OpenUrl CrossRef PubMed 22. ↵ Nogueira RG , Liebeskind DS , Sung G , Duckwiler G , Smith WS ; MERCI; Multi MERCI Writing Committee. Predictors of good clinical outcomes, mortality, and successful revascularization in patients with acute ischemic stroke undergoing thrombectomy: pooled analysis of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi MERCI Trials . Stroke . 2009 ; 40 : 3777 – 3783 . OpenUrl Abstract / FREE Full Text View the discussion thread. Back to top Previous Next Posted November 06, 2024. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. 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