Deans' stroke musings: Endovascular Thrombectomy >24-hr From Stroke Symptom Onset

Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Tuesday, July 17, 2018

Endovascular Thrombectomy >24-hr From Stroke Symptom Onset

So it is safe at least for those cherry picked candidates. What needs to be done after this to get the patient 100% recovered?
https://www.frontiersin.org/articles/10.3389/fneur.2018.00501/full?

Nathan W. Manning^1,2,3,4,5^*,

Jason Wenderoth^1,2,3,4,

Khalid Alsahli⁶,

Dennis Cordato^3,7,8,

Cecilia Cappelen-Smith^3,7,8,

Alan McDougall^3,7,8,

Alessandro S. Zagami^4,9 and

Andrew Cheung^1,2,3

¹Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia
²Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
³Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
⁴Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
⁵Florey Institute of Neuroscience, Parkville, VIC, Australia
⁶Department of Radiology, Liverpool Hospital, Liverpool, NSW, Australia
⁷Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia
⁸South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
⁹Department of Neurology, Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, NSW, Australia

Background: Trials have demonstrated efficacy for endovascular thrombectomy (EVT) for anterior circulation acute ischaemic stroke (AIS) up to 24-h from symptom onset. The magnitude of effect suggests benefit may exist beyond 24-h.

Objectives: To perform a retrospective review of all patients undergoing EVT for anterior circulation LVO stroke beyond 24-h from symptom onset and assess safety and efficacy.

Methods: A prospectively maintained database of EVT patients treated at two comprehensive stroke centers between January 2016 and December 2017 was retrospectively screened. Patients undergoing EVT for anterior circulation AIS >24-h from symptom onset were selected.

Results: A total of 429 AIS patient underwent EVT in the study period. Five patients treated >24-h from symptom onset were identified. The median age was 72 (range 42–84); median ASPECTS 8 (range 6–8); median baseline-NIHSS 9 (range 4–17); and median time from symptom onset to groin puncture 44 h and 55 min (range 25:07-90:10). One patient underwent CT perfusion imaging. The remaining four patients were selected based on non-contrast CT brain and CT-angiography. Two patients had tandem cervical carotid lesions and underwent acute stenting. Modified thrombolysis in cerebral ischaemia (mTICI) 3 reperfusion was achieved in four patients. No hemorrhagic transformation occurred. All patients were alive at 90-day follow-up. Four patients achieved functional independence at 90-days (mRS 0-2).

Conclusion: Endovascular thrombectomy for AIS patients beyond 24-h from symptom onset appears to be safe and effective in this limited study. There is a need for further evidence-based trials of benefit vs. risk in very prolonged time windows.

Introduction

Endovascular thrombectomy (EVT) is an established treatment for acute ischaemic stroke secondary to large vessel occlusion (LVO) of the anterior circulation (1). Recent randomized control trials (RCTs) have demonstrated a marked treatment effect for EVT versus standard care out to 24-h from symptom onset. These RCTs incorporated advanced neuroimaging techniques to select patients with small infarct cores (2, 3). Patients selected in this way presumably represent a subset of stroke patients with slow progression of the ischaemic core into the penumbra (4). In such patients it is possible that the treatment window may extend well-beyond 24-h. As ischaemic changes become increasingly apparent on non-contrast computed tomography (CT) brain scans over time (5), it is possible that this modality may have increased sensitivity for determining the infarct core at delayed time windows.

We present a retrospective review of our experience treating acute ischaemic stroke patients with LVO of the anterior circulation beyond 24-h from symptom onset. The aim of this analysis is to explore the safety and effectiveness of EVT in very extended time windows. We hypothesize that EVT can be safely and effectively performed well-beyond 24 h from symptom onset in a subset of patients.